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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___ Chief Complaint: Respiratory distress, increased mechanical ventilator support Major Surgical or Invasive Procedure: ___ L femoral CVL placement History of Present Illness: ___ yom HTN, advanced COPD, recently here with severe refractory hypercarbic respiratory failure attributed to acute COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who presents for his ___ re-admission ___ since ___ for leukocytosis, overnight agitation and elevated peak airway pressures on the mechanical ventilator with evidence for auto-PEEP over night. Patient was recently admitted from ___ to ___ for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. He was re-admitted on ___ - ___ for altered mental status (sedation) and hypercarbia, both of which improved with adjustment of his ventilator. Initial concern for was for infection, but work-up for infection and metabolic derangements were unremarkable. Ultimately, this period of altered mental status was contributed to sedation from home methadone and seroquel. He was subsequently re-admitted ___ - ___ for acute onset abdominal pain with nausea/vomiting with concern from rehab for intestinal ischemia. He received CTA A/P which was negative. Symptoms resolved by arrival to the floor. Bowel regimen scaled up with BM prior to discharge. He was also decreased on his PSV from ___ to ___ with daily trach mask trials lasting up to 20min. He is now presenting with multiple concerns. ___ direct signout from rehab provider they cite: (1) agitation overnight and somnolence during the day (2) high peak airway pressures during his overnight agitation with evidence for auto-PRRP with concern this represents COPD exacerbation (3) ongoing tachycardia of unclear etiology with normal TTE and trial of 4L IVF over the course of the last week (4) increasing leukocytosis . For the above, they have attempted to increase night time Seroquel to 50mg qhs. They have continued duonebs for COPD and are concerned that the downtitration of his prednisone brought about his exacerbation but have not yet increased his dosing. His tachycardia was treated with fluids, also found to have a low TSH with free T3/T4 pending. Lastly they have a clean CXR, clean urine and no clear source of infection but have started vancomycin empirically at rehab due to hx of MRSA growth ___ sputum ___ the past. On arrival to the ICU he appears calm and is breathing comfortable. He says he feels warm and that lately his breathing has been worse but that this has fluctuated. He asks us to update ___ (HCP). Otherwise he denies more sputum, denies ns, chills, denies CP, abd pain, n/v. ROS: Positives as per HPI; otherwise negative. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== General: Patient sitting upright ___ bed, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach ___ place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally ___ UE and ___. SLTIT DISCHARGE PHYSICAL EXAM: =========================== VS: T 99.2 BP 142/95 HR 110 SaO2 100% on trach mask with FiO2 30% General: Patient sitting upright ___ bed, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach ___ place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: CTAB, no wheezing or crackles Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally ___ UE and ___ Pertinent Results: ADMISSION LABS: ================ ___ 05:30PM BLOOD WBC-19.2* RBC-2.85* Hgb-9.4* Hct-30.6* MCV-107* MCH-33.0* MCHC-30.7* RDW-16.2* RDWSD-65.1* Plt ___ ___ 05:30PM BLOOD ___ PTT-32.3 ___ ___ 05:30PM BLOOD Glucose-128* UreaN-11 Creat-0.4* Na-141 K-6.1* Cl-100 HCO3-35* AnGap-6* ___ 05:30PM BLOOD ALT-33 AST-18 LD(LDH)-232 AlkPhos-96 TotBili-<0.2 ___ 05:30PM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.7 Mg-2.3 ___ 05:55PM BLOOD ___ pO2-48* pCO2-82* pH-7.29* calTCO2-41* Base XS-9 ___ 05:55PM BLOOD Lactate-1.1 DISCHARGE LABS: ================ ___ 03:15AM BLOOD WBC-11.9* RBC-2.53* Hgb-8.2* Hct-26.8* MCV-106* MCH-32.4* MCHC-30.6* RDW-15.8* RDWSD-60.7* Plt ___ ___ 03:15AM BLOOD ___ PTT-27.9 ___ ___ 03:15AM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-144 K-3.9 Cl-101 HCO3-33* AnGap-10 ___ 03:15AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.2 MICROBIOLOGY: =============== ___ URINE CULTURE PROBABLE ENTEROCOCCUS. ~7000 CFU/mL. STAPHYLOCOCCUS SPECIES. ~1000 CFU/mL. ___ SPUTUM CULTURE >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S STUDIES/IMAGING: ================= ___ CXR Comparison to ___. The lung volumes are normal and stable. The tracheostomy tube is ___ stable position. There is no evidence of pneumothorax. Stable normal size of the cardiac silhouette with mild elongation of the descending aorta. The current image provides no evidence of pneumonia or other parenchymal pathology. No pleural effusions. Brief Hospital Course: TRANSITIONAL MANAGEMENT: ========================= [] Prednisone taper: 2 more doses of 40mg daily with last day ___, then resume 5mg daily, wean from there as tolerated [] New inhaler regimen for SEVERE COPD: - levalbuterol 1 IH Q4H PRN for shortness of breath - please start him on a long acting beta agonist and long acting anticholinergic based on your formulary and availability - please start him on Flovent or other inhaled corticosteroid when his oral prednisone is discontinued [] He is taking cephalexin for MSSA tracheobronchitis, LAST DAY is ___ (10 day course) [] Please continue morphine 5mg PO Q2H, the indication is both shortness of breath and anxiety. Ok to uptitrate if patient is not too somnolent. If additional medication is needed, consider lorazepam PO 0.5mg Q4H PRN. SUMMARY: ========= Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who presented for his ___ re-admission ___ since ___ for leukocytosis, overnight agitation and elevated peak pressures on vent with auto-peep. Low suspicion for PNA given unremarkable CXR, and ultimately treated for COPD exacerbation. ACUTE ISSUES: =================== # Acute COPD exacerbation # Acute on chronic Hypercarbic respiratory failure # Sepsis secondary to Pneumonia Febrile to 100.7 on arrival with purulent appearing sputum. Why he has had so much difficulty with weaning off vent over the last 2 months has been unclear. He has a reported hx of COPD but recent CT Chest without marked parenchymal disease/emphysema. Though ___ PFTs obtained from ___ reported FEV1/FVC 0.36; FEV1 0.78 (28% predicted); FVC 2.2 (61% predicted); High reserve volume (indicative of hyperinflation & air trapping). Given multiple markers for obstructive process, he was treated for COPD exacerbation brought on by pneumonia with prednisone 40mg QD x5 days total (ending ___. Sputum cultures grew MSSA although CXR did not show obvious consolidation, so this was felt to be reflective of tracheobronchitis. Broad antibiotics were narrowed to Keflex for a 10-day course (___) ___ addition to steroids. Although he has been essentially on trach ventilator since ___, we were able to have him undergo periods of trach mask every day with good effect, mainly limited by subjective dyspnea and tiring out. # Agitation # Pain # Anxiety During recent hospitalization, he was discharged on Seroquel and methadone which was transitioned to oxycodone. Standing daily Seroquel was converted to QHS as he did not demonstrate any delirium for which it had been started. Given anxiety could well be driving a great many of his symptoms, psychiatry and palliative care were consulted. Psychiatry evaluated him but did not recommend starting additional psychiatric medications. Palliative Care recommended morphine Q2H and uptitrate as needed, as well as consider benzodiazepines as second line (consider lorazepam 0.5mg PO q4h PRN dyspnea/anxiety) if needed. The patient also was able to speak to a chaplain which he found to be helpful. CHRONIC ISSUES: ======================= #RUE DVT During previous hospitalization, ultrasound (___) revealed acute DVT ___ right internal jugular vein. Home lovenox was continued. #BPH Has acute retention at rehab with difficult and traumatic foley placement each time. Foley was continued per ___ request given that difficult and traumatic foley placement each time, though it was exchanged while inpatient given positive urine cultures. Continued home Tamsulosin 0.4 mg PO QHS. CODE: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 3. Enoxaparin Sodium 70 mg SC Q12H 4. Ipratropium Bromide Neb 1 NEB IH Q6H 5. Omeprazole 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. PredniSONE 5 mg PO DAILY 8. QUEtiapine Fumarate 25 mg PO QID 9. QUEtiapine Fumarate 50 mg PO QHS 10. Simethicone 80 mg PO QID:PRN gas 11. Tamsulosin 0.4 mg PO QHS 12. Thiamine 100 mg PO DAILY 13. Finasteride 5 mg PO DAILY 14. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 15. Bisacodyl ___AILY 16. Cyanocobalamin 1000 mcg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. Docusate Sodium (Liquid) 100 mg PO BID 19. Lactulose 10 mL PO DAILY 20. melatonin 3 mg oral QHS 21. Nystatin Oral Suspension 5 mL PO QID 22. senna leaf extract ___ mg oral BID 23. TraZODone 25 mg PO BID:PRN agitation, anxiety 24. Potassium Chloride (Powder) 40 mEq PO DAILY 25. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 26. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H Discharge Medications: 1. Cephalexin 500 mg PO/NG Q6H 2. GuaiFENesin ___ mL PO Q6H:PRN cough 3. Levalbuterol Neb 0.63 mg NEB Q4H:PRN shortness of breath 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg PO Q2H:PRN SOB 5. PredniSONE 40 mg PO DAILY Duration: 5 Days 6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 7. Bisacodyl ___AILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Enoxaparin Sodium 70 mg SC Q12H 11. Finasteride 5 mg PO DAILY 12. Lactulose 10 mL PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 16. Nystatin Oral Suspension 5 mL PO QID 17. Omeprazole 40 mg PO DAILY 18. Polyethylene Glycol 17 g PO DAILY 19. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 4.5 20. QUEtiapine Fumarate 50 mg PO QHS 21. senna leaf extract ___ mg oral BID 22. Simethicone 80 mg PO QID:PRN gas 23. Tamsulosin 0.4 mg PO QHS 24. Thiamine 100 mg PO DAILY 25. TraZODone 25 mg PO BID:PRN agitation, anxiety Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hypercarbic respiratory failure COPD exacerbation MSSA tracheobronchitis Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you. You were admitted to the hospital because you had difficulty breathing, high heart rate, and some confusion, and there was a concern that you had a COPD exacerbation. You were treated with steroids and antibiotics. You were seen by the respiratory therapists who worked on optimizing your breathing. You were started on morphine to help with the sensation of difficulty breathing. You were seen by Psychiatry specialists who felt your current medications were working well. You were discharged on some new medications and inhalers which you should continue to take. Please follow up with your outpatient providers as scheduled. Sincerely, Your ___ Team Followup Instructions: ___
[ "A419", "J15211", "J9622", "J441", "Z9911", "J440", "I82C11", "E873", "F17210", "I10", "R000", "F419", "N400", "N401", "R338", "R319", "G8929", "Z22322", "Z930", "Z931", "K5903", "T402X5A", "J40" ]
Allergies: Precedex Chief Complaint: Respiratory distress, increased mechanical ventilator support Major Surgical or Invasive Procedure: [MASKED] L femoral CVL placement History of Present Illness: [MASKED] yom HTN, advanced COPD, recently here with severe refractory hypercarbic respiratory failure attributed to acute COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], ventilator dependent, who presents for his [MASKED] re-admission [MASKED] since [MASKED] for leukocytosis, overnight agitation and elevated peak airway pressures on the mechanical ventilator with evidence for auto-PEEP over night. Patient was recently admitted from [MASKED] to [MASKED] for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. He was re-admitted on [MASKED] - [MASKED] for altered mental status (sedation) and hypercarbia, both of which improved with adjustment of his ventilator. Initial concern for was for infection, but work-up for infection and metabolic derangements were unremarkable. Ultimately, this period of altered mental status was contributed to sedation from home methadone and seroquel. He was subsequently re-admitted [MASKED] - [MASKED] for acute onset abdominal pain with nausea/vomiting with concern from rehab for intestinal ischemia. He received CTA A/P which was negative. Symptoms resolved by arrival to the floor. Bowel regimen scaled up with BM prior to discharge. He was also decreased on his PSV from [MASKED] to [MASKED] with daily trach mask trials lasting up to 20min. He is now presenting with multiple concerns. [MASKED] direct signout from rehab provider they cite: (1) agitation overnight and somnolence during the day (2) high peak airway pressures during his overnight agitation with evidence for auto-PRRP with concern this represents COPD exacerbation (3) ongoing tachycardia of unclear etiology with normal TTE and trial of 4L IVF over the course of the last week (4) increasing leukocytosis . For the above, they have attempted to increase night time Seroquel to 50mg qhs. They have continued duonebs for COPD and are concerned that the downtitration of his prednisone brought about his exacerbation but have not yet increased his dosing. His tachycardia was treated with fluids, also found to have a low TSH with free T3/T4 pending. Lastly they have a clean CXR, clean urine and no clear source of infection but have started vancomycin empirically at rehab due to hx of MRSA growth [MASKED] sputum [MASKED] the past. On arrival to the ICU he appears calm and is breathing comfortable. He says he feels warm and that lately his breathing has been worse but that this has fluctuated. He asks us to update [MASKED] (HCP). Otherwise he denies more sputum, denies ns, chills, denies CP, abd pain, n/v. ROS: Positives as per HPI; otherwise negative. Past Medical History: COPD HTN Appendectomy Social History: [MASKED] Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== General: Patient sitting upright [MASKED] bed, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach [MASKED] place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: [MASKED] strength bilaterally [MASKED] UE and [MASKED]. SLTIT DISCHARGE PHYSICAL EXAM: =========================== VS: T 99.2 BP 142/95 HR 110 SaO2 100% on trach mask with FiO2 30% General: Patient sitting upright [MASKED] bed, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach [MASKED] place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: CTAB, no wheezing or crackles Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: [MASKED] strength bilaterally [MASKED] UE and [MASKED] Pertinent Results: ADMISSION LABS: ================ [MASKED] 05:30PM BLOOD WBC-19.2* RBC-2.85* Hgb-9.4* Hct-30.6* MCV-107* MCH-33.0* MCHC-30.7* RDW-16.2* RDWSD-65.1* Plt [MASKED] [MASKED] 05:30PM BLOOD [MASKED] PTT-32.3 [MASKED] [MASKED] 05:30PM BLOOD Glucose-128* UreaN-11 Creat-0.4* Na-141 K-6.1* Cl-100 HCO3-35* AnGap-6* [MASKED] 05:30PM BLOOD ALT-33 AST-18 LD(LDH)-232 AlkPhos-96 TotBili-<0.2 [MASKED] 05:30PM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.7 Mg-2.3 [MASKED] 05:55PM BLOOD [MASKED] pO2-48* pCO2-82* pH-7.29* calTCO2-41* Base XS-9 [MASKED] 05:55PM BLOOD Lactate-1.1 DISCHARGE LABS: ================ [MASKED] 03:15AM BLOOD WBC-11.9* RBC-2.53* Hgb-8.2* Hct-26.8* MCV-106* MCH-32.4* MCHC-30.6* RDW-15.8* RDWSD-60.7* Plt [MASKED] [MASKED] 03:15AM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 03:15AM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-144 K-3.9 Cl-101 HCO3-33* AnGap-10 [MASKED] 03:15AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.2 MICROBIOLOGY: =============== [MASKED] URINE CULTURE PROBABLE ENTEROCOCCUS. ~7000 CFU/mL. STAPHYLOCOCCUS SPECIES. ~1000 CFU/mL. [MASKED] SPUTUM CULTURE >25 PMNs and <10 epithelial cells/100X field. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S STUDIES/IMAGING: ================= [MASKED] CXR Comparison to [MASKED]. The lung volumes are normal and stable. The tracheostomy tube is [MASKED] stable position. There is no evidence of pneumothorax. Stable normal size of the cardiac silhouette with mild elongation of the descending aorta. The current image provides no evidence of pneumonia or other parenchymal pathology. No pleural effusions. Brief Hospital Course: TRANSITIONAL MANAGEMENT: ========================= [] Prednisone taper: 2 more doses of 40mg daily with last day [MASKED], then resume 5mg daily, wean from there as tolerated [] New inhaler regimen for SEVERE COPD: - levalbuterol 1 IH Q4H PRN for shortness of breath - please start him on a long acting beta agonist and long acting anticholinergic based on your formulary and availability - please start him on Flovent or other inhaled corticosteroid when his oral prednisone is discontinued [] He is taking cephalexin for MSSA tracheobronchitis, LAST DAY is [MASKED] (10 day course) [] Please continue morphine 5mg PO Q2H, the indication is both shortness of breath and anxiety. Ok to uptitrate if patient is not too somnolent. If additional medication is needed, consider lorazepam PO 0.5mg Q4H PRN. SUMMARY: ========= Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure [MASKED] COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], ventilator dependent, who presented for his [MASKED] re-admission [MASKED] since [MASKED] for leukocytosis, overnight agitation and elevated peak pressures on vent with auto-peep. Low suspicion for PNA given unremarkable CXR, and ultimately treated for COPD exacerbation. ACUTE ISSUES: =================== # Acute COPD exacerbation # Acute on chronic Hypercarbic respiratory failure # Sepsis secondary to Pneumonia Febrile to 100.7 on arrival with purulent appearing sputum. Why he has had so much difficulty with weaning off vent over the last 2 months has been unclear. He has a reported hx of COPD but recent CT Chest without marked parenchymal disease/emphysema. Though [MASKED] PFTs obtained from [MASKED] reported FEV1/FVC 0.36; FEV1 0.78 (28% predicted); FVC 2.2 (61% predicted); High reserve volume (indicative of hyperinflation & air trapping). Given multiple markers for obstructive process, he was treated for COPD exacerbation brought on by pneumonia with prednisone 40mg QD x5 days total (ending [MASKED]. Sputum cultures grew MSSA although CXR did not show obvious consolidation, so this was felt to be reflective of tracheobronchitis. Broad antibiotics were narrowed to Keflex for a 10-day course ([MASKED]) [MASKED] addition to steroids. Although he has been essentially on trach ventilator since [MASKED], we were able to have him undergo periods of trach mask every day with good effect, mainly limited by subjective dyspnea and tiring out. # Agitation # Pain # Anxiety During recent hospitalization, he was discharged on Seroquel and methadone which was transitioned to oxycodone. Standing daily Seroquel was converted to QHS as he did not demonstrate any delirium for which it had been started. Given anxiety could well be driving a great many of his symptoms, psychiatry and palliative care were consulted. Psychiatry evaluated him but did not recommend starting additional psychiatric medications. Palliative Care recommended morphine Q2H and uptitrate as needed, as well as consider benzodiazepines as second line (consider lorazepam 0.5mg PO q4h PRN dyspnea/anxiety) if needed. The patient also was able to speak to a chaplain which he found to be helpful. CHRONIC ISSUES: ======================= #RUE DVT During previous hospitalization, ultrasound ([MASKED]) revealed acute DVT [MASKED] right internal jugular vein. Home lovenox was continued. #BPH Has acute retention at rehab with difficult and traumatic foley placement each time. Foley was continued per [MASKED] request given that difficult and traumatic foley placement each time, though it was exchanged while inpatient given positive urine cultures. Continued home Tamsulosin 0.4 mg PO QHS. CODE: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 3. Enoxaparin Sodium 70 mg SC Q12H 4. Ipratropium Bromide Neb 1 NEB IH Q6H 5. Omeprazole 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. PredniSONE 5 mg PO DAILY 8. QUEtiapine Fumarate 25 mg PO QID 9. QUEtiapine Fumarate 50 mg PO QHS 10. Simethicone 80 mg PO QID:PRN gas 11. Tamsulosin 0.4 mg PO QHS 12. Thiamine 100 mg PO DAILY 13. Finasteride 5 mg PO DAILY 14. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 15. Bisacodyl AILY 16. Cyanocobalamin 1000 mcg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. Docusate Sodium (Liquid) 100 mg PO BID 19. Lactulose 10 mL PO DAILY 20. melatonin 3 mg oral QHS 21. Nystatin Oral Suspension 5 mL PO QID 22. senna leaf extract [MASKED] mg oral BID 23. TraZODone 25 mg PO BID:PRN agitation, anxiety 24. Potassium Chloride (Powder) 40 mEq PO DAILY 25. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 26. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H Discharge Medications: 1. Cephalexin 500 mg PO/NG Q6H 2. GuaiFENesin [MASKED] mL PO Q6H:PRN cough 3. Levalbuterol Neb 0.63 mg NEB Q4H:PRN shortness of breath 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg PO Q2H:PRN SOB 5. PredniSONE 40 mg PO DAILY Duration: 5 Days 6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 7. Bisacodyl AILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Enoxaparin Sodium 70 mg SC Q12H 11. Finasteride 5 mg PO DAILY 12. Lactulose 10 mL PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 16. Nystatin Oral Suspension 5 mL PO QID 17. Omeprazole 40 mg PO DAILY 18. Polyethylene Glycol 17 g PO DAILY 19. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 4.5 20. QUEtiapine Fumarate 50 mg PO QHS 21. senna leaf extract [MASKED] mg oral BID 22. Simethicone 80 mg PO QID:PRN gas 23. Tamsulosin 0.4 mg PO QHS 24. Thiamine 100 mg PO DAILY 25. TraZODone 25 mg PO BID:PRN agitation, anxiety Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Hypercarbic respiratory failure COPD exacerbation MSSA tracheobronchitis Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you. You were admitted to the hospital because you had difficulty breathing, high heart rate, and some confusion, and there was a concern that you had a COPD exacerbation. You were treated with steroids and antibiotics. You were seen by the respiratory therapists who worked on optimizing your breathing. You were started on morphine to help with the sensation of difficulty breathing. You were seen by Psychiatry specialists who felt your current medications were working well. You were discharged on some new medications and inhalers which you should continue to take. Please follow up with your outpatient providers as scheduled. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "F17210", "I10", "F419", "N400", "G8929" ]
[ "A419: Sepsis, unspecified organism", "J15211: Pneumonia due to Methicillin susceptible Staphylococcus aureus", "J9622: Acute and chronic respiratory failure with hypercapnia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z9911: Dependence on respirator [ventilator] status", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "I82C11: Acute embolism and thrombosis of right internal jugular vein", "E873: Alkalosis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "R000: Tachycardia, unspecified", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "R319: Hematuria, unspecified", "G8929: Other chronic pain", "Z22322: Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus", "Z930: Tracheostomy status", "Z931: Gastrostomy status", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "J40: Bronchitis, not specified as acute or chronic" ]
10,049,041
22,620,123
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___. Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. Patient was recently admitted from ___ to ___ for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. He was re-admitted on ___ for altered mental status (sedation) and hypercarbia, both of which improved with adjustment of his ventilator. Initial concern for was for infection, but work-up for infection and metabolic derangements were unremarkable. Ultimately, this period of altered mental status was contributed to sedation from home methadone and seroquel. Last night, he developed vomiting x3. This was non-bloody, non-bilious and associated with LLQ and LUQ pain with diarrhea. Normal bowel movment yesterday. Also with Tmax of 99.9. Denies HA, CP, SOB, dysuria. He was sent to the ED from his rehab for concerns of intestinal ischemia/obstruction/perf. In the ED, a CTA ABD & PELVIS was performed which was unremarkable. He was noted to have worsening copious secretions from trach and had episodes of satting into the ___. Diaphoretic. Given no intra-abdominal infection, initial suspicion is that it is possible pulmonary etiology. Portable CXR initially read with RML PNA and was started on vancomycin and Zosyn. CXR read finalized with no evidence of pneumonia. Admitted to the ICU due to ventilation with trach. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: Temp: 98.3, BP: 188/128, HR: 121, RR: 16, 97% O2 vent General: Patient lying in bed, pleasant, no apparent distress, awake aware and oriented Ãâ€"3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Minimally tender, abdomen distended Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally in UE and ___. SLTIT. DISCHARGE PHYSICAL EXAM Mental status: He is alert. He resonds appropriately to questions though has a delayed response. He will either write our mouth words. At times, he does not respond and then will say that he is tired of talking. He is agitated at times though admits to feeling anxious. General: Patient sitting upright in chair, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally in UE and ___. SLTIT. Pertinent Results: Admission labs: =============== ___ 03:49PM BLOOD WBC-15.9* RBC-2.97* Hgb-9.6* Hct-31.9* MCV-107* MCH-32.3* MCHC-30.1* RDW-17.6* RDWSD-67.5* Plt ___ ___ 03:49PM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-145 K-4.1 Cl-99 HCO3-36* AnGap-10 ___ 03:49PM BLOOD ALT-97* AST-53* AlkPhos-108 TotBili-0.2 ___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 Discharge labs: =============== ___ 03:04AM BLOOD WBC-9.0 RBC-2.69* Hgb-8.7* Hct-28.4* MCV-106* MCH-32.3* MCHC-30.6* RDW-17.0* RDWSD-65.3* Plt ___ ___ 03:04AM BLOOD ___ PTT-30.1 ___ ___ 03:04AM BLOOD Plt ___ ___ 03:04AM BLOOD Glucose-121* UreaN-5* Creat-0.4* Na-140 K-3.6 Cl-97 HCO3-31 AnGap-12 ___ 03:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7 Pertinent labs: =============== ___ 12:48PM BLOOD ___ pO2-46* pCO2-66* pH-7.36 calTCO2-39* Base XS-8 ___ 09:43PM BLOOD ___ pO2-59* pCO2-59* pH-7.42 calTCO2-40* Base XS-10 ___ 11:33AM BLOOD ___ pO2-78* pCO2-58* pH-7.41 calTCO2-38* Base XS-9 ___ 06:19AM BLOOD ___ pO2-46* pCO2-68* pH-7.34* calTCO2-38* Base XS-7 ___ 01:11AM BLOOD ___ pO2-42* pCO2-79* pH-7.30* calTCO2-40* Base XS-8 ___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 IMAGING: ========= ___ Imaging CTA ABD & PELVIS FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.2 x 0.9 cm hypoattenuating lesion at the hepatic dome may reflect a simple hepatic cyst or biliary hamartoma (03:18). 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: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Bilateral renal cortical hypodensities are too small to fully characterize. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Patient is status post PEG tube placement. Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder is decompressed with Foley catheter in place. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. Seminal vesicles are grossly unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Small foci of gas in the left upper abdomen may be related to prior injection (3:100). IMPRESSION: No acute findings in the abdomen or pelvis to account for patient's symptoms, specifically no convincing signs of bowel ischemia. ___ Imaging PORTABLE ABDOMEN IMPRESSION: There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. The stomach is slightly distended with air, similar to prior CT. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Brief Hospital Course: ASSESSMENT ========== Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. ACUTE ISSUES ======================= #Trach and vent dependent #Hypercarbic respiratory failure #Primary Respiratory Acidosis with Secondary Metabolic Alkalosis: No current concern for infection. Per history, he has COPD, however he does not necessarily present as COPD, though unclear what the underlying process is. Tolerated vent mask for approximately 20 min on ___ before requiring PSV. However PSV decreased from ___ to ___ which he is tolerating well. Unfortunately, we had to scale back to ___ at 30% an hour prior to discharge due to an elevated CO2 (66). Moving forward, we recommend daily trach mask trials as long as patient can tolerate. #Constipation Tympanic abdominal percussion on exam, and has not had BM since he was admitted. History of severe constipation which was attributed to opioid use. With resolution of his initial GI symptoms, he was restarted on tube feeds and his home bowel regimen was slowly added back on. He had one bowel movement on the day prior to discharge. #Tachycardia #HTN Noted to have initially low UOP. Gave 1L of fluids with improvement of UOP but only mild improvement of HR. ___ his baseline HR or iso of anxiety. We recommend treating anxiety appropriately though if pressures remain elevated, initiation of anti-HTN therapy. #Vomiting - resolved #Diarrhea - resolved #Leukocytosis - improving Acute presentation of vomiting x3, diarrhea, abdominal pain, and leukocytosis. However, he is now stating he had no abdominal pain. Remainder of symptoms fully resolved by time he arrived to ICU. Unclear exactly why he has been repeatedly sent in. CTA abdomen and pelvis unremarkable for any acute etiology. Likely gastroenteritis (given leukocytosis) vs constipation with overflow vs medication overuse (Bisacodyl PR, Docusate BID, Lactulose, miralax, Senna). He was restarted on tube feeds. #Pain #Anxiety During recent admission, patient was on prolonged fentanyl drip iso of extended intubation. He was thus transitioned to methadone, dilaudid, seroquel due to concern with potential opioid withdrawal, and tapered to just Seroquel QHS and a methadone at discharge. The methadone was then switched to oxycodone PRN for pain control, and the Seroquel dose was reduced on the most recent admission on ___ for concerns of over sedation. He was continued on home home QUEtiapine Fumarate 25 mg PO QID + 25mg QHS. Currently getting a total of 125mg/25. Per rehab documentation, they have been slowly tapering the Seroquel off. He was continued on home OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN and home TraZODone 25 mg PO BID:PRN agitation, anxiety. CHRONIC ISSUES ======================= #RUE DVT Ultrasound on ___ revealed acute DVT in right internal jugular vein. Lovenox was started on ___. He was continued on home lovenox. #Abnormal liver tests Persistently mildly elevated in hepatocellular pattern with highLDH as well. Improved since prior admission one month ago. LDH high but normal hemolysis labs and CK on prior admission. #Hematuria Noted on prior admissions and present during this hospitalizations. #BPH Continue home Tamsulosin 0.4 mg PO QHS TRANSITIONAL ISSUES: ===================== [ ] Continue to taper his ventilation as tolerated. We were initially able to reduce pressure support to ___ at 30% with no change in VBG but had to scale back to ___ at 30% an hour prior to discharge due to an elevated CO2 (66). His CO2 was 58 on prior day. Please perform daily trach mask trials. [ ] Follow up his bowel movements. He had one bowel movement on the day prior to discharge. [ ] Noted to have hematuria - please consider further evaluation if this continues [ ] Continue to taper his steroid [ ] Continue to taper his Seroquel [ ] Consider PJP prophylaxis given long-term steroid use [ ] He is iron deficient. Suggest PO iron supplementation Q48H for increased absorption and less constipation. [ ] Recommend treatment of blood pressure if continually elevated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl ___AILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 5. Ipratropium Bromide Neb 2 NEB IH Q6H 6. Lactulose 10 mL PO DAILY 7. melatonin 3 mg oral QHS 8. Multivitamins 1 TAB PO DAILY 9. Nystatin Oral Suspension 5 mL PO QID 10. Omeprazole 40 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Potassium Chloride (Powder) 40 mEq PO DAILY 13. QUEtiapine Fumarate 25 mg PO QID 14. QUEtiapine Fumarate 25 mg PO QHS 15. senna leaf extract ___ mg oral BID 16. Tamsulosin 0.4 mg PO QHS 17. Thiamine 100 mg PO DAILY 18. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 19. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 21. Simethicone 80 mg PO QID:PRN gas 22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 23. TraZODone 25 mg PO BID:PRN agitation, anxiety 24. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 25. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 4. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 5. Bisacodyl ___AILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Docusate Sodium (Liquid) 100 mg PO BID 8. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 9. Ipratropium Bromide Neb 2 NEB IH Q6H 10. Lactulose 10 mL PO DAILY 11. melatonin 3 mg oral QHS 12. Multivitamins 1 TAB PO DAILY 13. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 14. Nystatin Oral Suspension 5 mL PO QID 15. Omeprazole 40 mg PO DAILY 16. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY 18. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 19. PredniSONE 5 mg PO DAILY 20. QUEtiapine Fumarate 25 mg PO QID 21. QUEtiapine Fumarate 25 mg PO QHS 22. senna leaf extract ___ mg oral BID 23. Simethicone 80 mg PO QID:PRN gas 24. Tamsulosin 0.4 mg PO QHS 25. Thiamine 100 mg PO DAILY 26. TraZODone 25 mg PO BID:PRN agitation, anxiety Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ========= # Gastroenteritis # Hypercarbic respiratory failure SECONDARY: =========== # Chronic constipation # COPD # Anxiety # DVT 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 caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You had vomiting and abdominal pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You had imaging which did not show any issues with the bowels - Your symptoms improved - You were given fluids - You were continued on the ventilator 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: ___
[ "K529", "J9692", "E874", "I82C11", "B9561", "F419", "Z22322", "F17210", "Z9981", "Z930", "Z934", "R7989", "R319", "N400", "I10", "K5909", "D72829", "R000", "T40605A" ]
Allergies: Precedex Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure [MASKED] COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. Patient was recently admitted from [MASKED] to [MASKED] for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. He was re-admitted on [MASKED] for altered mental status (sedation) and hypercarbia, both of which improved with adjustment of his ventilator. Initial concern for was for infection, but work-up for infection and metabolic derangements were unremarkable. Ultimately, this period of altered mental status was contributed to sedation from home methadone and seroquel. Last night, he developed vomiting x3. This was non-bloody, non-bilious and associated with LLQ and LUQ pain with diarrhea. Normal bowel movment yesterday. Also with Tmax of 99.9. Denies HA, CP, SOB, dysuria. He was sent to the ED from his rehab for concerns of intestinal ischemia/obstruction/perf. In the ED, a CTA ABD & PELVIS was performed which was unremarkable. He was noted to have worsening copious secretions from trach and had episodes of satting into the [MASKED]. Diaphoretic. Given no intra-abdominal infection, initial suspicion is that it is possible pulmonary etiology. Portable CXR initially read with RML PNA and was started on vancomycin and Zosyn. CXR read finalized with no evidence of pneumonia. Admitted to the ICU due to ventilation with trach. Past Medical History: COPD HTN Appendectomy Social History: [MASKED] Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: Temp: 98.3, BP: 188/128, HR: 121, RR: 16, 97% O2 vent General: Patient lying in bed, pleasant, no apparent distress, awake aware and oriented Ãâ€"3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Minimally tender, abdomen distended Extremities: 2+ pulses bilaterally Neuro: [MASKED] strength bilaterally in UE and [MASKED]. SLTIT. DISCHARGE PHYSICAL EXAM Mental status: He is alert. He resonds appropriately to questions though has a delayed response. He will either write our mouth words. At times, he does not respond and then will say that he is tired of talking. He is agitated at times though admits to feeling anxious. General: Patient sitting upright in chair, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: [MASKED] strength bilaterally in UE and [MASKED]. SLTIT. Pertinent Results: Admission labs: =============== [MASKED] 03:49PM BLOOD WBC-15.9* RBC-2.97* Hgb-9.6* Hct-31.9* MCV-107* MCH-32.3* MCHC-30.1* RDW-17.6* RDWSD-67.5* Plt [MASKED] [MASKED] 03:49PM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-145 K-4.1 Cl-99 HCO3-36* AnGap-10 [MASKED] 03:49PM BLOOD ALT-97* AST-53* AlkPhos-108 TotBili-0.2 [MASKED] 03:58PM BLOOD [MASKED] pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 Discharge labs: =============== [MASKED] 03:04AM BLOOD WBC-9.0 RBC-2.69* Hgb-8.7* Hct-28.4* MCV-106* MCH-32.3* MCHC-30.6* RDW-17.0* RDWSD-65.3* Plt [MASKED] [MASKED] 03:04AM BLOOD [MASKED] PTT-30.1 [MASKED] [MASKED] 03:04AM BLOOD Plt [MASKED] [MASKED] 03:04AM BLOOD Glucose-121* UreaN-5* Creat-0.4* Na-140 K-3.6 Cl-97 HCO3-31 AnGap-12 [MASKED] 03:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7 Pertinent labs: =============== [MASKED] 12:48PM BLOOD [MASKED] pO2-46* pCO2-66* pH-7.36 calTCO2-39* Base XS-8 [MASKED] 09:43PM BLOOD [MASKED] pO2-59* pCO2-59* pH-7.42 calTCO2-40* Base XS-10 [MASKED] 11:33AM BLOOD [MASKED] pO2-78* pCO2-58* pH-7.41 calTCO2-38* Base XS-9 [MASKED] 06:19AM BLOOD [MASKED] pO2-46* pCO2-68* pH-7.34* calTCO2-38* Base XS-7 [MASKED] 01:11AM BLOOD [MASKED] pO2-42* pCO2-79* pH-7.30* calTCO2-40* Base XS-8 [MASKED] 03:58PM BLOOD [MASKED] pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 IMAGING: ========= [MASKED] Imaging CTA ABD & PELVIS FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.2 x 0.9 cm hypoattenuating lesion at the hepatic dome may reflect a simple hepatic cyst or biliary hamartoma (03:18). 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: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Bilateral renal cortical hypodensities are too small to fully characterize. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Patient is status post PEG tube placement. Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder is decompressed with Foley catheter in place. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. Seminal vesicles are grossly unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Small foci of gas in the left upper abdomen may be related to prior injection (3:100). IMPRESSION: No acute findings in the abdomen or pelvis to account for patient's symptoms, specifically no convincing signs of bowel ischemia. [MASKED] Imaging PORTABLE ABDOMEN IMPRESSION: There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. The stomach is slightly distended with air, similar to prior CT. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Brief Hospital Course: ASSESSMENT ========== Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure [MASKED] COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. ACUTE ISSUES ======================= #Trach and vent dependent #Hypercarbic respiratory failure #Primary Respiratory Acidosis with Secondary Metabolic Alkalosis: No current concern for infection. Per history, he has COPD, however he does not necessarily present as COPD, though unclear what the underlying process is. Tolerated vent mask for approximately 20 min on [MASKED] before requiring PSV. However PSV decreased from [MASKED] to [MASKED] which he is tolerating well. Unfortunately, we had to scale back to [MASKED] at 30% an hour prior to discharge due to an elevated CO2 (66). Moving forward, we recommend daily trach mask trials as long as patient can tolerate. #Constipation Tympanic abdominal percussion on exam, and has not had BM since he was admitted. History of severe constipation which was attributed to opioid use. With resolution of his initial GI symptoms, he was restarted on tube feeds and his home bowel regimen was slowly added back on. He had one bowel movement on the day prior to discharge. #Tachycardia #HTN Noted to have initially low UOP. Gave 1L of fluids with improvement of UOP but only mild improvement of HR. [MASKED] his baseline HR or iso of anxiety. We recommend treating anxiety appropriately though if pressures remain elevated, initiation of anti-HTN therapy. #Vomiting - resolved #Diarrhea - resolved #Leukocytosis - improving Acute presentation of vomiting x3, diarrhea, abdominal pain, and leukocytosis. However, he is now stating he had no abdominal pain. Remainder of symptoms fully resolved by time he arrived to ICU. Unclear exactly why he has been repeatedly sent in. CTA abdomen and pelvis unremarkable for any acute etiology. Likely gastroenteritis (given leukocytosis) vs constipation with overflow vs medication overuse (Bisacodyl PR, Docusate BID, Lactulose, miralax, Senna). He was restarted on tube feeds. #Pain #Anxiety During recent admission, patient was on prolonged fentanyl drip iso of extended intubation. He was thus transitioned to methadone, dilaudid, seroquel due to concern with potential opioid withdrawal, and tapered to just Seroquel QHS and a methadone at discharge. The methadone was then switched to oxycodone PRN for pain control, and the Seroquel dose was reduced on the most recent admission on [MASKED] for concerns of over sedation. He was continued on home home QUEtiapine Fumarate 25 mg PO QID + 25mg QHS. Currently getting a total of 125mg/25. Per rehab documentation, they have been slowly tapering the Seroquel off. He was continued on home OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN and home TraZODone 25 mg PO BID:PRN agitation, anxiety. CHRONIC ISSUES ======================= #RUE DVT Ultrasound on [MASKED] revealed acute DVT in right internal jugular vein. Lovenox was started on [MASKED]. He was continued on home lovenox. #Abnormal liver tests Persistently mildly elevated in hepatocellular pattern with highLDH as well. Improved since prior admission one month ago. LDH high but normal hemolysis labs and CK on prior admission. #Hematuria Noted on prior admissions and present during this hospitalizations. #BPH Continue home Tamsulosin 0.4 mg PO QHS TRANSITIONAL ISSUES: ===================== [ ] Continue to taper his ventilation as tolerated. We were initially able to reduce pressure support to [MASKED] at 30% with no change in VBG but had to scale back to [MASKED] at 30% an hour prior to discharge due to an elevated CO2 (66). His CO2 was 58 on prior day. Please perform daily trach mask trials. [ ] Follow up his bowel movements. He had one bowel movement on the day prior to discharge. [ ] Noted to have hematuria - please consider further evaluation if this continues [ ] Continue to taper his steroid [ ] Continue to taper his Seroquel [ ] Consider PJP prophylaxis given long-term steroid use [ ] He is iron deficient. Suggest PO iron supplementation Q48H for increased absorption and less constipation. [ ] Recommend treatment of blood pressure if continually elevated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl AILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 70 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time 5. Ipratropium Bromide Neb 2 NEB IH Q6H 6. Lactulose 10 mL PO DAILY 7. melatonin 3 mg oral QHS 8. Multivitamins 1 TAB PO DAILY 9. Nystatin Oral Suspension 5 mL PO QID 10. Omeprazole 40 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Potassium Chloride (Powder) 40 mEq PO DAILY 13. QUEtiapine Fumarate 25 mg PO QID 14. QUEtiapine Fumarate 25 mg PO QHS 15. senna leaf extract [MASKED] mg oral BID 16. Tamsulosin 0.4 mg PO QHS 17. Thiamine 100 mg PO DAILY 18. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 19. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 21. Simethicone 80 mg PO QID:PRN gas 22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 23. TraZODone 25 mg PO BID:PRN agitation, anxiety 24. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 25. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 4. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 5. Bisacodyl AILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Docusate Sodium (Liquid) 100 mg PO BID 8. Enoxaparin Sodium 70 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time 9. Ipratropium Bromide Neb 2 NEB IH Q6H 10. Lactulose 10 mL PO DAILY 11. melatonin 3 mg oral QHS 12. Multivitamins 1 TAB PO DAILY 13. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 14. Nystatin Oral Suspension 5 mL PO QID 15. Omeprazole 40 mg PO DAILY 16. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY 18. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 19. PredniSONE 5 mg PO DAILY 20. QUEtiapine Fumarate 25 mg PO QID 21. QUEtiapine Fumarate 25 mg PO QHS 22. senna leaf extract [MASKED] mg oral BID 23. Simethicone 80 mg PO QID:PRN gas 24. Tamsulosin 0.4 mg PO QHS 25. Thiamine 100 mg PO DAILY 26. TraZODone 25 mg PO BID:PRN agitation, anxiety Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: ========= # Gastroenteritis # Hypercarbic respiratory failure SECONDARY: =========== # Chronic constipation # COPD # Anxiety # DVT 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 caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You had vomiting and abdominal pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You had imaging which did not show any issues with the bowels - Your symptoms improved - You were given fluids - You were continued on the ventilator 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]
[]
[ "F419", "F17210", "N400", "I10" ]
[ "K529: Noninfective gastroenteritis and colitis, unspecified", "J9692: Respiratory failure, unspecified with hypercapnia", "E874: Mixed disorder of acid-base balance", "I82C11: Acute embolism and thrombosis of right internal jugular vein", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "F419: Anxiety disorder, unspecified", "Z22322: Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z9981: Dependence on supplemental oxygen", "Z930: Tracheostomy status", "Z934: Other artificial openings of gastrointestinal tract status", "R7989: Other specified abnormal findings of blood chemistry", "R319: Hematuria, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I10: Essential (primary) hypertension", "K5909: Other constipation", "D72829: Elevated white blood cell count, unspecified", "R000: Tachycardia, unspecified", "T40605A: Adverse effect of unspecified narcotics, initial encounter" ]
10,049,041
23,314,477
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex / ibuprofen Attending: ___. Chief Complaint: word finding difficulties with concern for intracranial hemorrhage Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who presented from an outside hospital with word finding difficulties with concern for intracranial hemorrhage. Per the referral note the patient initially presented to an ___ with word finding difficulty and a head CT which demonstrated a hemorrhagic bleed. His chest x-ray also demonstrated a lung mass which was new and concerning for malignancy. The patient was on Lovenox for a prior DVT and this was reversed with Lovenox. The patient was recently admitted to ___ ICUs multiple times from ___ for refractory Hypercarbic respiratory failure and inability to wean the vent leading to tracheotsomy and PEG tube with course complicated by MSSA bacteremia. He was discharged to rehab. He was then re-admitted on ___ for AMS and hypercarbia which was fixed by adjusting vent setting. His most recent admission was from ___ he was treated for an acute COPD exacerbation after presenting with acute on chronic Hypercarbic respiratory failure. He was discharged to ___ and was successfully decannulated at ___. Speaking with his rehab center he has been on a baseline 02 requirement of 2L He was having word finding difficulty acutely yesterday morning. He is usually oriented X3, feeds himself, dresses himself and has no weakness. He was doing well with his new inhaler at the rehab. He has been having some aspiration difficulty with swallowing so was on a ground safety diet. In the ED, the patient had worsening tachypnea and SVT and HTN and was started on a nicardapine gtt. They were planning on obtaining a CT head and CTA torso for both PE and malignancy evaluation but this was deferred due to respiratory distress. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: HR 107 BP 150/87 96% on 2L NC (baseline is 2L NC) GENERAL: lying in bed awake and alert, having a difficult time with expressing himself, answering questions and following commands HEENT:PERRL, Sclera anicteric and without injection. MMM. CARDIAC: rapid rate and rhythm, no murmurs gallops or rubs LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: expressive aphasia DISCHARGE PHYSICAL EXAM ======================== VITALS: ___ 0749 Temp: 98.5 PO BP: 98/70 L Lying HR: 95 RR: 20 O2 sat: 95% O2 delivery: 1 L GENERAL: Chronically-ill appearing male sitting up in chair in NAD. Alert and interactive HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. Trach site healed. No facial droop. Tongue midline. No oropharyngela erythema or exudates. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Decreased work of breathing throughout all lung fields. Not using accessory muscles. No wheezes ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No clubbing, cyanosis. Trace ___. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. AAOx3 although notable word-finding difficulties PSYCH: appropriate mood and affect Pertinent Results: ADMISSION LABS ================== ___ 09:10PM BLOOD WBC-11.7* RBC-3.96* Hgb-11.2* Hct-36.5* MCV-92 MCH-28.3 MCHC-30.7* RDW-16.1* RDWSD-54.4* Plt ___ ___ 09:10PM BLOOD ___ PTT-34.5 ___ ___ 09:10PM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-139 K-5.9* Cl-96 HCO3-30 AnGap-13 ___ 09:20AM BLOOD Glucose-71 UreaN-9 Creat-0.7 Na-139 K-4.3 Cl-96 HCO3-28 AnGap-15 ___ 09:10PM BLOOD ALT-36 AST-53* AlkPhos-85 TotBili-0.2 ___ 09:20AM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.7 Mg-1.5* ___ 09:14PM BLOOD ___ pO2-30* pCO2-60* pH-7.37 calTCO2-36* Base XS-6 DISCHARGE LABS ================== ___ 06:00AM BLOOD WBC-13.8* RBC-3.97* Hgb-11.6* Hct-38.2* MCV-96 MCH-29.2 MCHC-30.4* RDW-17.1* RDWSD-60.4* Plt ___ ___ 06:00AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-138 K-4.7 Cl-96 HCO3-34* AnGap-8* ___ 06:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 PERTINENT IMAGING ================== ___ CXR Redemonstration of round densities in the right hilum and right lung base, may be evaluated with nonemergent CT. No pneumothorax. ___ NCCTH Interval increase in size of 4.2 cm hemorrhagic lesion in the left temporoparietal area. Minimal change in 3 mm rightward midline shift, previously 2 mm. No evidence of herniation. ___ CT-TORSO 1. A 3.3 cm pleural-based lesion at the right lung base, new from ___ and suspicious for malignancy. 2. Asymmetric thickening of the right side of the anus and lower rectal wall. Recommend direct visualization with possible anoscopy to exclude an underlying mass. 3. A 16 mm lytic lesion in the right scapula with sclerotic margins, which is incompletely characterized, but may represent a metastasis. 4. Multiple ill-defined nodules measuring up to 6 mm in the right lower lobe, which are favored to be infectious or inflammatory, though metastatic lesions cannot be entirely excluded. Additional small nodules in the bilateral upper lobes. Attention on ___ imaging is recommended. 5. Prostatomegaly. ___ CXR 1. Small right apical pneumothorax. 2. Large mass at the right hemidiaphragm is better evaluated on prior CT. ___ 1. Trace right-sided pneumothorax with chest tube in situ. No short-term change in pleural mass. 2. Moderate to severe emphysema. 3. Finding suggest bronchomalacia. 4. Two small nodules in the right lower lobe amenable for ___ surveillance depending on clinical circumstances and result of pleural mass biopsy. ___ CXR No visible pneumothorax. ___ FDG-PET-CT 1. Irregular nodular thickening and patchy FDG uptake in the diaphragm is nonspecific and of uncertain etiology. 2. A pleural based soft tissue density in the right lower lobe is non FDG avid. 3. Mild, diffusely increased FDG uptake throughout the axial skeleton is suggestive of bone marrow stimulation. 4. Although better appreciated on previous head CTs, re-demonstrated is a non avid focus of hemorrhage in the left temporoparietal lobe with vasogenic edema and mild mass effect. ___ ___ 1. Continued evolution of the left temporoparietal hemorrhagic mass with surrounding vasogenic edema. Specifically, there is decreased hyperdensity of the hemorrhagic area, which appears less well-defined. The degree of surrounding vasogenic edema is not significantly changed. 2. Persistent 5 mm rightward midline shift and continued mass-effect on the posterior body of the left lateral ventricle. No evidence of hydrocephalus. ___ CTA HEAD/NECK 1. Head CT shows evolution of left parietal hematoma with unchanged surrounding vasogenic edema and mass effect. 2. No significant abnormalities on CT angiography of the head. No abnormal vascular structures are seen, aneurysms are identified or signs of venous sinus thrombosis. 3. No vascular occlusion or stenosis in the neck. ___ MR BRAIN ___ OPINION 1. Left parietal hemorrhagic lesion with an enhancing mural nodule and rim enhancement are suspicious for an underlying mass. While a cavernous malformation is in differential diagnosis, the nodular enhancement is not typical and would suggest other possibilities such as metastatic disease. 2. Foci of chronic microhemorrhage in the right periatrial region. 3. A ___ MRI would be helpful for better assessment. ___ CXR Hyperinflation and emphysema. No evidence of acute cardiopulmonary disease. PROCEDURE NOTES =============== ___ FLEX-SIG Poor prep ___ FLEX-SIG Poor prep ___ FLEX-SIG - Small non-bleeding hemorrhoids - No rectal or sigmoid mass seen ___ ___ Guided pleural biopsy 1. 3.0 x 2.4 cm pleural mass was biopsied showing maroon tinged fragments. 2. Moderate right postprocedural pneumothorax satisfactory drained after placement of a pigtail catheter. PATHOLOGY ========= ___ LUNG BIOPSY Sections with organizing fibrin and hemorrage with hemosiderin deposition, fibrosis and chronic inflammation. ___ and GMS stains, performed on both samples, are negative. Scant alveolar lung parenchyma with scaring and reactive pneumocytes (highlighted by TTF-1 positivity) is present. CDX-2 is negative. No overt malignancy is identified. Case reviewed with Dr. ___ ___. Brief Hospital Course: PATIENT SUMMARY =============== ___ year old man who presented with acute onset confusion and expressive aphasia, found on imaging to have hemorrhagic left temporal-parietal mass, right pleural mass, and rectal thickening initially concerning for metastatic malignancy. Malignancy exonerated below the neck with flexible sigmoidoscopy x3, ___ pleural biopsy complicated by pneumothorax (resolved), and PET-CT. He received treatment for his COPD exacerbation likely triggered by too steep of a steroid taper that required a brief visit to the ICU for BIPAP titration. He improved and was transferred on the floor, with oxygen requirement of none to 1L for patient comfort. He will be continued on a steroid taper. He was discharged in stable condition to acute rehab with continued expressive aphasia likely from this brain mass (hemorrhagic stroke versus hemorrhagic brain mass). TRANSITIONAL ISSUES =================== [ ] Patient will need follow up CT non con head on ___ [ ] Patient will need follow up MRI brain on ___ [ ] Patient will need follow up neurology appointment on ___ [ ] Patient discharged on slow dexamethasone taper (___) as listed below - 4 mg qd x4 days (___) - 2 mg qd x4 days (___) - 1 mg qd x4 days (___) [ ] Patient's average O2 saturation in mid-high ___ on 1L, with 95% saturation on room air with ambulation therefore may not require home O2 but may continue for patient comfort as he is anxious without it [ ] Patient was started on anti-hypertensives this admission, please titrate for goal of SBP <160 [ ] Consider starting patient on an SSRI for his anxiety as well as his post-stroke outcomes ACUTE ISSUES ============ # Temporal/parietal mass # Expressive aphasia Given acute presentation with expressive aphasia and hemorrhagic brain mass identified on imaging. He received IV dexamethasone and Keppra to mitigate vasogenic edema and seizure risk. Further imaging revealed a pleural mass and rectal thickening. This pattern was concerning for a metastatic malignancy. The leading hypothesis was lung cancer given history of COPD that was metastatic to the brain, with possible concomitant early rectal cancer. Colon cancer metastatic to the brain with concomitant lung cancer was also considered. Flexible sigmoidoscopy x3 was attempted due to inadequate preparations, but rectal cancer was eventually exonerated. ___ guided pleural biopsy was undertaken which demonstrated hematoma and fibrous tissue and was negative for malignancy. Finally a PET-CT was done which exonerated malignancy outside of the cranium. Currently the etiology of the brain mass is hemorrhagic stroke versus hemorrhagic brain mass (possibly malignancy) in the setting of anticoagulation with lovenox. He will receive a follow up MRI brain and neurology appointment on ___ with ___ imaging: Noncon CT head in 4 week, MRI brain with contrast in 6 weeks. He is on a slower steroid taper (see schedule in COPD problem course below) for his brain mass as a more aggressive taper likely caused a COPD exacerbation. He will also be maintained on Keppra 1g twice daily. # Hypertension New diagnosis on admission with SBPs 130-1470s. Due to recent brain mass findings with hemorrhagic stroke on the differential, he will need to have blood pressure control for goal SBP 160. He was initially on labetalol 200mg BID which was switched to lisinopril given his COPD. He will be discharged on lisinopril 5mg daily with need to continue to monitor and titrate according to SBP which was previously in the ___ in response to lisinopril 10mg daily. # Acute on chronic hypoxic respiratory failure # COPD exacerbations # History of multiple intubations # Status post reversed tracheostomy Patient known to have a history of COPD, and chest x rays during admission were consistent with this. He triggered once for abnormal vital signs (including tachypnea) however it is believed that this was due to recurrence of an iatrogenic pneumothorax. He received multiple chest x rays for subjective shortness of breath however these episodes were more consistent with anxiety rather than COPD exacerbation. Patient then retriggered on ___ for stridor and hypoxia, likely a COPD exacerbation secondary to a too steep steroid taper. ENT evaluated him and no signs of vocal cord dysfunction. CXR without acute process. Returned to the medicine floor with continued treated of scheduled inhalers and as need nebulizers. Ambulatory sats 93% on room air, will likely not require home O2, may continue at low volumes ~1L for comfort as patient is very anxious without it and may be a possible trigger for dyspneic episodes. His goal O2 sat is 88-92%. He will continue on a steroid taper dexamethasone 4 mg PO x4 days ___, 2 mg IV x4 days ___, and 1 mg PO x4 days ___. He should be continued on Bactrim prophylaxis while on steroids. For inhalers, he is on Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H, Budesonide 1 mg IH BID, Tiotropium Bromide 1 CAP IH DAILY. For rescue inhalers he is on duonebs q6H PRN, levalbuterol q4H PRN. # Anxiety Likely a strong contributor to tachypnea. Patient was maintained on lorazepam 0.5mg BID. # Pneumothorax On ___ Mr. ___ underwent ___ guided pleural biopsy of his right pleural mass. Unfortunately this was complicated by an iatrogenic pneumothorax. A chest tube was placed and placed to suction after the procedure which was successful in reducing the pneumothorax. The following day weaning of the chest tube was attempted, however this unfortunately resulted in a trigger for abnormal vital signs (tachycardia and tachypnea). The etiology of this was believed to be recurrence of the pneumothorax without evidence of tension as it resolved by putting the chest tube back to suction. Eventually he was successfully weaned off the chest tube and the chest tube was pulled without recurrence of the pneumothorax. # Pleural hematoma Admission CT was remarkable for a right lower pleural mass. As malignancy was on the differential, this was biopsied via ___ guidance. Pathology revealed it was a hematoma and had no evidence of a malignant process. PET-CT was consistent with this conclusion. # Rectal thickening Noted on admission CT. As rectal thickening can be seen in malignancy, anoscopy and flex-sig x3 was undertaken which exonerated him of malignancy. PET-CT was consistent with this conclusion. # Leukocytosis Started soon after admission, and was believed likely secondary to corticosteroids. However it continued to increase during admission, and it was entertained to be possibly paraneoplastic, however at the time of discharge this has been called into question. A careful search for an infectious source was negative for ongoing infection. CHRONIC ISSUES ============== # Right upper extremity DVT Following discharge from his previous hospitalization on ___, Mr. ___ was found to have a right upper extremity deep vein thrombosus that was believed to be related to a central line. This was discovered at ___. He was placed on lovenox for anticoagulation. As he was still on lovenox during his presentation this was held as the risk of progressive/recurrent bleeding outweighed the risk for recurrent deep vein thrombosis. He was eventually started on subcutaneous heparin for DVT prophylaxis. He was monitored for recurrence of his deep vein thrombosis however it did not declare itself. # ?HFpEF The patient was on lasix prior to admission, likely as there was belief at one time that volume status was contributing to his episodes of respiratory distress. His most recent echo on ___ showed an EF of 75% with a low-normal cardiac index. As he appeared euvolemic on admission lasix was held. He remained euvolemic during his admission and did not require diuresis. # Normocytic anemia Likely ___ chronic illness. # BPH Home tamsulosin and finasteride was continued during this admission. # B12 deficiency # Nutrition Continued MVI, thiamine and B12 replacement # GERD Continued home omeprazole # Allergies Continued home fluticasone. ====================== #CODE STATUS: DNR OK to intubate #CONTACT: ___ ___: Sister Phone number: ___ Cell phone: ___ Medications on Admission: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 2. Bisacodyl ___AILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Enoxaparin Sodium 70 mg SC Q12H 5. Finasteride 5 mg PO QHS 6. Tamsulosin 0.4 mg PO QHS 7. Thiamine 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. melatonin 5 mg oral QHS 11. Docusate Sodium (Liquid) 200 mg PO DAILY 12. Ipratropium Bromide Neb 1 NEB IH Q6H 13. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 14. Fleet Enema (Saline) 1 Enema PR ONCE 15. Fluticasone Propionate NASAL 1 SPRY NU DAILY 16. Furosemide 60 mg PO DAILY 17. Metoprolol Succinate XL 100 mg PO DAILY 18. ALPRAZolam 0.25 mg PO QHS 19. Budesonide 0.5 mg IH BID Discharge Medications: 1. Dexamethasone 2 mg PO DAILY Duration: 4 Doses 2. Dexamethasone 1 mg PO DAILY Duration: 4 Doses 3. LevETIRAcetam 1000 mg PO Q12H 4. Lisinopril 5 mg PO DAILY 5. LORazepam 0.5 mg PO/IV BID anxiety 6. Magnesium Oxide 400 mg PO BID Duration: 2 Doses 7. Polyethylene Glycol 17 g PO DAILY 8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 9. Senna 8.6 mg PO BID 10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY please take while on dexamethasone, then stop 11. Tiotropium Bromide 1 CAP IH DAILY 12. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 13. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 14. Bisacodyl ___AILY 15. Budesonide 0.5 mg IH BID 16. Cyanocobalamin 1000 mcg PO DAILY 17. Docusate Sodium (Liquid) 200 mg PO DAILY 18. Finasteride 5 mg PO QHS 19. Fluticasone Propionate NASAL 1 SPRY NU DAILY 20. Ipratropium Bromide MDI 2 PUFF IH Q6H 21. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 22. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 23. melatonin 5 mg oral QHS 24. Multivitamins 1 TAB PO DAILY 25. Omeprazole 20 mg PO DAILY 26. Tamsulosin 0.4 mg PO QHS 27. Thiamine 100 mg PO DAILY 28. HELD- Enoxaparin Sodium 70 mg SC Q12H This medication was held. Do not restart Enoxaparin Sodium until repeat imaging of your brain mass 29. HELD- Furosemide 60 mg PO DAILY This medication was held. Do not restart Furosemide until fluid overloaded Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Expressive aphasia Acute on chronic hypoxic respiratory failure SECONDARY DIAGNOSIS =================== Pneumothorax COPD exacerbation Hemorrhagic parietal brain mass (etiology unknown) Hypertension Anxiety Leukocytosis 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 confused and had difficulty speaking. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received medications to treat the mass in your brain which is likely a blood collection from a recent stroke. - We used a scope to evaluate your rectum for cancer and did not find any - We took a biopsy of your lung to look for cancer and did not find any - Unfortunately there was a complication with the lung biopsy and we had to place a tube in your chest to stabilize it. - Your lung stabilized and returned to normal. - You began to feel better and were ready to leave the hospital. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and ___ with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "I619", "I5033", "G936", "J9621", "R4701", "I471", "J441", "J95811", "J942", "I82721", "G9340", "D430", "I110", "F419", "K6289", "D72829", "Z66", "Y838", "Y810", "Y92238", "Z7901", "D649", "N400", "K219", "R1310", "K648", "Z87891", "Z9981" ]
Allergies: Precedex / ibuprofen Chief Complaint: word finding difficulties with concern for intracranial hemorrhage Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure [MASKED] COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], ventilator dependent, who presented from an outside hospital with word finding difficulties with concern for intracranial hemorrhage. Per the referral note the patient initially presented to an [MASKED] with word finding difficulty and a head CT which demonstrated a hemorrhagic bleed. His chest x-ray also demonstrated a lung mass which was new and concerning for malignancy. The patient was on Lovenox for a prior DVT and this was reversed with Lovenox. The patient was recently admitted to [MASKED] ICUs multiple times from [MASKED] for refractory Hypercarbic respiratory failure and inability to wean the vent leading to tracheotsomy and PEG tube with course complicated by MSSA bacteremia. He was discharged to rehab. He was then re-admitted on [MASKED] for AMS and hypercarbia which was fixed by adjusting vent setting. His most recent admission was from [MASKED] he was treated for an acute COPD exacerbation after presenting with acute on chronic Hypercarbic respiratory failure. He was discharged to [MASKED] and was successfully decannulated at [MASKED]. Speaking with his rehab center he has been on a baseline 02 requirement of 2L He was having word finding difficulty acutely yesterday morning. He is usually oriented X3, feeds himself, dresses himself and has no weakness. He was doing well with his new inhaler at the rehab. He has been having some aspiration difficulty with swallowing so was on a ground safety diet. In the ED, the patient had worsening tachypnea and SVT and HTN and was started on a nicardapine gtt. They were planning on obtaining a CT head and CTA torso for both PE and malignancy evaluation but this was deferred due to respiratory distress. Past Medical History: COPD HTN Appendectomy Social History: [MASKED] Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: HR 107 BP 150/87 96% on 2L NC (baseline is 2L NC) GENERAL: lying in bed awake and alert, having a difficult time with expressing himself, answering questions and following commands HEENT:PERRL, Sclera anicteric and without injection. MMM. CARDIAC: rapid rate and rhythm, no murmurs gallops or rubs LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: expressive aphasia DISCHARGE PHYSICAL EXAM ======================== VITALS: [MASKED] 0749 Temp: 98.5 PO BP: 98/70 L Lying HR: 95 RR: 20 O2 sat: 95% O2 delivery: 1 L GENERAL: Chronically-ill appearing male sitting up in chair in NAD. Alert and interactive HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. Trach site healed. No facial droop. Tongue midline. No oropharyngela erythema or exudates. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Decreased work of breathing throughout all lung fields. Not using accessory muscles. No wheezes ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No clubbing, cyanosis. Trace [MASKED]. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. AAOx3 although notable word-finding difficulties PSYCH: appropriate mood and affect Pertinent Results: ADMISSION LABS ================== [MASKED] 09:10PM BLOOD WBC-11.7* RBC-3.96* Hgb-11.2* Hct-36.5* MCV-92 MCH-28.3 MCHC-30.7* RDW-16.1* RDWSD-54.4* Plt [MASKED] [MASKED] 09:10PM BLOOD [MASKED] PTT-34.5 [MASKED] [MASKED] 09:10PM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-139 K-5.9* Cl-96 HCO3-30 AnGap-13 [MASKED] 09:20AM BLOOD Glucose-71 UreaN-9 Creat-0.7 Na-139 K-4.3 Cl-96 HCO3-28 AnGap-15 [MASKED] 09:10PM BLOOD ALT-36 AST-53* AlkPhos-85 TotBili-0.2 [MASKED] 09:20AM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.7 Mg-1.5* [MASKED] 09:14PM BLOOD [MASKED] pO2-30* pCO2-60* pH-7.37 calTCO2-36* Base XS-6 DISCHARGE LABS ================== [MASKED] 06:00AM BLOOD WBC-13.8* RBC-3.97* Hgb-11.6* Hct-38.2* MCV-96 MCH-29.2 MCHC-30.4* RDW-17.1* RDWSD-60.4* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-138 K-4.7 Cl-96 HCO3-34* AnGap-8* [MASKED] 06:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 PERTINENT IMAGING ================== [MASKED] CXR Redemonstration of round densities in the right hilum and right lung base, may be evaluated with nonemergent CT. No pneumothorax. [MASKED] NCCTH Interval increase in size of 4.2 cm hemorrhagic lesion in the left temporoparietal area. Minimal change in 3 mm rightward midline shift, previously 2 mm. No evidence of herniation. [MASKED] CT-TORSO 1. A 3.3 cm pleural-based lesion at the right lung base, new from [MASKED] and suspicious for malignancy. 2. Asymmetric thickening of the right side of the anus and lower rectal wall. Recommend direct visualization with possible anoscopy to exclude an underlying mass. 3. A 16 mm lytic lesion in the right scapula with sclerotic margins, which is incompletely characterized, but may represent a metastasis. 4. Multiple ill-defined nodules measuring up to 6 mm in the right lower lobe, which are favored to be infectious or inflammatory, though metastatic lesions cannot be entirely excluded. Additional small nodules in the bilateral upper lobes. Attention on [MASKED] imaging is recommended. 5. Prostatomegaly. [MASKED] CXR 1. Small right apical pneumothorax. 2. Large mass at the right hemidiaphragm is better evaluated on prior CT. [MASKED] 1. Trace right-sided pneumothorax with chest tube in situ. No short-term change in pleural mass. 2. Moderate to severe emphysema. 3. Finding suggest bronchomalacia. 4. Two small nodules in the right lower lobe amenable for [MASKED] surveillance depending on clinical circumstances and result of pleural mass biopsy. [MASKED] CXR No visible pneumothorax. [MASKED] FDG-PET-CT 1. Irregular nodular thickening and patchy FDG uptake in the diaphragm is nonspecific and of uncertain etiology. 2. A pleural based soft tissue density in the right lower lobe is non FDG avid. 3. Mild, diffusely increased FDG uptake throughout the axial skeleton is suggestive of bone marrow stimulation. 4. Although better appreciated on previous head CTs, re-demonstrated is a non avid focus of hemorrhage in the left temporoparietal lobe with vasogenic edema and mild mass effect. [MASKED] [MASKED] 1. Continued evolution of the left temporoparietal hemorrhagic mass with surrounding vasogenic edema. Specifically, there is decreased hyperdensity of the hemorrhagic area, which appears less well-defined. The degree of surrounding vasogenic edema is not significantly changed. 2. Persistent 5 mm rightward midline shift and continued mass-effect on the posterior body of the left lateral ventricle. No evidence of hydrocephalus. [MASKED] CTA HEAD/NECK 1. Head CT shows evolution of left parietal hematoma with unchanged surrounding vasogenic edema and mass effect. 2. No significant abnormalities on CT angiography of the head. No abnormal vascular structures are seen, aneurysms are identified or signs of venous sinus thrombosis. 3. No vascular occlusion or stenosis in the neck. [MASKED] MR BRAIN [MASKED] OPINION 1. Left parietal hemorrhagic lesion with an enhancing mural nodule and rim enhancement are suspicious for an underlying mass. While a cavernous malformation is in differential diagnosis, the nodular enhancement is not typical and would suggest other possibilities such as metastatic disease. 2. Foci of chronic microhemorrhage in the right periatrial region. 3. A [MASKED] MRI would be helpful for better assessment. [MASKED] CXR Hyperinflation and emphysema. No evidence of acute cardiopulmonary disease. PROCEDURE NOTES =============== [MASKED] FLEX-SIG Poor prep [MASKED] FLEX-SIG Poor prep [MASKED] FLEX-SIG - Small non-bleeding hemorrhoids - No rectal or sigmoid mass seen [MASKED] [MASKED] Guided pleural biopsy 1. 3.0 x 2.4 cm pleural mass was biopsied showing maroon tinged fragments. 2. Moderate right postprocedural pneumothorax satisfactory drained after placement of a pigtail catheter. PATHOLOGY ========= [MASKED] LUNG BIOPSY Sections with organizing fibrin and hemorrage with hemosiderin deposition, fibrosis and chronic inflammation. [MASKED] and GMS stains, performed on both samples, are negative. Scant alveolar lung parenchyma with scaring and reactive pneumocytes (highlighted by TTF-1 positivity) is present. CDX-2 is negative. No overt malignancy is identified. Case reviewed with Dr. [MASKED] [MASKED]. Brief Hospital Course: PATIENT SUMMARY =============== [MASKED] year old man who presented with acute onset confusion and expressive aphasia, found on imaging to have hemorrhagic left temporal-parietal mass, right pleural mass, and rectal thickening initially concerning for metastatic malignancy. Malignancy exonerated below the neck with flexible sigmoidoscopy x3, [MASKED] pleural biopsy complicated by pneumothorax (resolved), and PET-CT. He received treatment for his COPD exacerbation likely triggered by too steep of a steroid taper that required a brief visit to the ICU for BIPAP titration. He improved and was transferred on the floor, with oxygen requirement of none to 1L for patient comfort. He will be continued on a steroid taper. He was discharged in stable condition to acute rehab with continued expressive aphasia likely from this brain mass (hemorrhagic stroke versus hemorrhagic brain mass). TRANSITIONAL ISSUES =================== [ ] Patient will need follow up CT non con head on [MASKED] [ ] Patient will need follow up MRI brain on [MASKED] [ ] Patient will need follow up neurology appointment on [MASKED] [ ] Patient discharged on slow dexamethasone taper ([MASKED]) as listed below - 4 mg qd x4 days ([MASKED]) - 2 mg qd x4 days ([MASKED]) - 1 mg qd x4 days ([MASKED]) [ ] Patient's average O2 saturation in mid-high [MASKED] on 1L, with 95% saturation on room air with ambulation therefore may not require home O2 but may continue for patient comfort as he is anxious without it [ ] Patient was started on anti-hypertensives this admission, please titrate for goal of SBP <160 [ ] Consider starting patient on an SSRI for his anxiety as well as his post-stroke outcomes ACUTE ISSUES ============ # Temporal/parietal mass # Expressive aphasia Given acute presentation with expressive aphasia and hemorrhagic brain mass identified on imaging. He received IV dexamethasone and Keppra to mitigate vasogenic edema and seizure risk. Further imaging revealed a pleural mass and rectal thickening. This pattern was concerning for a metastatic malignancy. The leading hypothesis was lung cancer given history of COPD that was metastatic to the brain, with possible concomitant early rectal cancer. Colon cancer metastatic to the brain with concomitant lung cancer was also considered. Flexible sigmoidoscopy x3 was attempted due to inadequate preparations, but rectal cancer was eventually exonerated. [MASKED] guided pleural biopsy was undertaken which demonstrated hematoma and fibrous tissue and was negative for malignancy. Finally a PET-CT was done which exonerated malignancy outside of the cranium. Currently the etiology of the brain mass is hemorrhagic stroke versus hemorrhagic brain mass (possibly malignancy) in the setting of anticoagulation with lovenox. He will receive a follow up MRI brain and neurology appointment on [MASKED] with [MASKED] imaging: Noncon CT head in 4 week, MRI brain with contrast in 6 weeks. He is on a slower steroid taper (see schedule in COPD problem course below) for his brain mass as a more aggressive taper likely caused a COPD exacerbation. He will also be maintained on Keppra 1g twice daily. # Hypertension New diagnosis on admission with SBPs 130-1470s. Due to recent brain mass findings with hemorrhagic stroke on the differential, he will need to have blood pressure control for goal SBP 160. He was initially on labetalol 200mg BID which was switched to lisinopril given his COPD. He will be discharged on lisinopril 5mg daily with need to continue to monitor and titrate according to SBP which was previously in the [MASKED] in response to lisinopril 10mg daily. # Acute on chronic hypoxic respiratory failure # COPD exacerbations # History of multiple intubations # Status post reversed tracheostomy Patient known to have a history of COPD, and chest x rays during admission were consistent with this. He triggered once for abnormal vital signs (including tachypnea) however it is believed that this was due to recurrence of an iatrogenic pneumothorax. He received multiple chest x rays for subjective shortness of breath however these episodes were more consistent with anxiety rather than COPD exacerbation. Patient then retriggered on [MASKED] for stridor and hypoxia, likely a COPD exacerbation secondary to a too steep steroid taper. ENT evaluated him and no signs of vocal cord dysfunction. CXR without acute process. Returned to the medicine floor with continued treated of scheduled inhalers and as need nebulizers. Ambulatory sats 93% on room air, will likely not require home O2, may continue at low volumes ~1L for comfort as patient is very anxious without it and may be a possible trigger for dyspneic episodes. His goal O2 sat is 88-92%. He will continue on a steroid taper dexamethasone 4 mg PO x4 days [MASKED], 2 mg IV x4 days [MASKED], and 1 mg PO x4 days [MASKED]. He should be continued on Bactrim prophylaxis while on steroids. For inhalers, he is on Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H, Budesonide 1 mg IH BID, Tiotropium Bromide 1 CAP IH DAILY. For rescue inhalers he is on duonebs q6H PRN, levalbuterol q4H PRN. # Anxiety Likely a strong contributor to tachypnea. Patient was maintained on lorazepam 0.5mg BID. # Pneumothorax On [MASKED] Mr. [MASKED] underwent [MASKED] guided pleural biopsy of his right pleural mass. Unfortunately this was complicated by an iatrogenic pneumothorax. A chest tube was placed and placed to suction after the procedure which was successful in reducing the pneumothorax. The following day weaning of the chest tube was attempted, however this unfortunately resulted in a trigger for abnormal vital signs (tachycardia and tachypnea). The etiology of this was believed to be recurrence of the pneumothorax without evidence of tension as it resolved by putting the chest tube back to suction. Eventually he was successfully weaned off the chest tube and the chest tube was pulled without recurrence of the pneumothorax. # Pleural hematoma Admission CT was remarkable for a right lower pleural mass. As malignancy was on the differential, this was biopsied via [MASKED] guidance. Pathology revealed it was a hematoma and had no evidence of a malignant process. PET-CT was consistent with this conclusion. # Rectal thickening Noted on admission CT. As rectal thickening can be seen in malignancy, anoscopy and flex-sig x3 was undertaken which exonerated him of malignancy. PET-CT was consistent with this conclusion. # Leukocytosis Started soon after admission, and was believed likely secondary to corticosteroids. However it continued to increase during admission, and it was entertained to be possibly paraneoplastic, however at the time of discharge this has been called into question. A careful search for an infectious source was negative for ongoing infection. CHRONIC ISSUES ============== # Right upper extremity DVT Following discharge from his previous hospitalization on [MASKED], Mr. [MASKED] was found to have a right upper extremity deep vein thrombosus that was believed to be related to a central line. This was discovered at [MASKED]. He was placed on lovenox for anticoagulation. As he was still on lovenox during his presentation this was held as the risk of progressive/recurrent bleeding outweighed the risk for recurrent deep vein thrombosis. He was eventually started on subcutaneous heparin for DVT prophylaxis. He was monitored for recurrence of his deep vein thrombosis however it did not declare itself. # ?HFpEF The patient was on lasix prior to admission, likely as there was belief at one time that volume status was contributing to his episodes of respiratory distress. His most recent echo on [MASKED] showed an EF of 75% with a low-normal cardiac index. As he appeared euvolemic on admission lasix was held. He remained euvolemic during his admission and did not require diuresis. # Normocytic anemia Likely [MASKED] chronic illness. # BPH Home tamsulosin and finasteride was continued during this admission. # B12 deficiency # Nutrition Continued MVI, thiamine and B12 replacement # GERD Continued home omeprazole # Allergies Continued home fluticasone. ====================== #CODE STATUS: DNR OK to intubate #CONTACT: [MASKED] [MASKED]: Sister Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 2. Bisacodyl AILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Enoxaparin Sodium 70 mg SC Q12H 5. Finasteride 5 mg PO QHS 6. Tamsulosin 0.4 mg PO QHS 7. Thiamine 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. melatonin 5 mg oral QHS 11. Docusate Sodium (Liquid) 200 mg PO DAILY 12. Ipratropium Bromide Neb 1 NEB IH Q6H 13. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 14. Fleet Enema (Saline) 1 Enema PR ONCE 15. Fluticasone Propionate NASAL 1 SPRY NU DAILY 16. Furosemide 60 mg PO DAILY 17. Metoprolol Succinate XL 100 mg PO DAILY 18. ALPRAZolam 0.25 mg PO QHS 19. Budesonide 0.5 mg IH BID Discharge Medications: 1. Dexamethasone 2 mg PO DAILY Duration: 4 Doses 2. Dexamethasone 1 mg PO DAILY Duration: 4 Doses 3. LevETIRAcetam 1000 mg PO Q12H 4. Lisinopril 5 mg PO DAILY 5. LORazepam 0.5 mg PO/IV BID anxiety 6. Magnesium Oxide 400 mg PO BID Duration: 2 Doses 7. Polyethylene Glycol 17 g PO DAILY 8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 9. Senna 8.6 mg PO BID 10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY please take while on dexamethasone, then stop 11. Tiotropium Bromide 1 CAP IH DAILY 12. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 13. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 14. Bisacodyl AILY 15. Budesonide 0.5 mg IH BID 16. Cyanocobalamin 1000 mcg PO DAILY 17. Docusate Sodium (Liquid) 200 mg PO DAILY 18. Finasteride 5 mg PO QHS 19. Fluticasone Propionate NASAL 1 SPRY NU DAILY 20. Ipratropium Bromide MDI 2 PUFF IH Q6H 21. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 22. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 23. melatonin 5 mg oral QHS 24. Multivitamins 1 TAB PO DAILY 25. Omeprazole 20 mg PO DAILY 26. Tamsulosin 0.4 mg PO QHS 27. Thiamine 100 mg PO DAILY 28. HELD- Enoxaparin Sodium 70 mg SC Q12H This medication was held. Do not restart Enoxaparin Sodium until repeat imaging of your brain mass 29. HELD- Furosemide 60 mg PO DAILY This medication was held. Do not restart Furosemide until fluid overloaded Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Expressive aphasia Acute on chronic hypoxic respiratory failure SECONDARY DIAGNOSIS =================== Pneumothorax COPD exacerbation Hemorrhagic parietal brain mass (etiology unknown) Hypertension Anxiety Leukocytosis 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 confused and had difficulty speaking. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received medications to treat the mass in your brain which is likely a blood collection from a recent stroke. - We used a scope to evaluate your rectum for cancer and did not find any - We took a biopsy of your lung to look for cancer and did not find any - Unfortunately there was a complication with the lung biopsy and we had to place a tube in your chest to stabilize it. - Your lung stabilized and returned to normal. - You began to feel better and were ready to leave the hospital. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and [MASKED] with your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I110", "F419", "Z66", "Z7901", "D649", "N400", "K219", "Z87891" ]
[ "I619: Nontraumatic intracerebral hemorrhage, unspecified", "I5033: Acute on chronic diastolic (congestive) heart failure", "G936: Cerebral edema", "J9621: Acute and chronic respiratory failure with hypoxia", "R4701: Aphasia", "I471: Supraventricular tachycardia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J95811: Postprocedural pneumothorax", "J942: Hemothorax", "I82721: Chronic embolism and thrombosis of deep veins of right upper extremity", "G9340: Encephalopathy, unspecified", "D430: Neoplasm of uncertain behavior of brain, supratentorial", "I110: Hypertensive heart disease with heart failure", "F419: Anxiety disorder, unspecified", "K6289: Other specified diseases of anus and rectum", "D72829: Elevated white blood cell count, unspecified", "Z66: Do not resuscitate", "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", "Y810: Diagnostic and monitoring general- and plastic-surgery devices associated with adverse incidents", "Y92238: Other place in hospital as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants", "D649: Anemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "R1310: Dysphagia, unspecified", "K648: Other hemorrhoids", "Z87891: Personal history of nicotine dependence", "Z9981: Dependence on supplemental oxygen" ]
10,049,041
25,320,808
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Tracheostomy/PEG placement ___ History of Present Illness: HPI: History obtained from ED and OMR as patient sedated. Mr. ___ is a ___ with a history of COPD, 45 pack-year smoking history, and HTN presenting with dyspnea. In ___ he presented to ___ for SOB and was admitted with hypercarbic respiratory failure secondary to a COPD exacerbation and influenza requiring short-term BiPAP. They were unable to wean him from O2 and he was discharged to ___ on ___ on 2L O2 and prednisone taper. When he arrived to rehab, the patient's dyspnea improved as did generalized weakness from his hospital stay. He then became more SOB in early ___ and had an EKG concerning for ST segment changes and he was referred to the ___ on ___ for a cardiac evaluation. His cardiac workup there was negative (negative EKG and symptomatology felt not be anginal), and they recommended ongoing ___ and smoking cessation as well as an outpatient TTE which has not been done. He then returned to rehab and subsequently developed worsening SOB, a nonproductive cough, and an episode of self-resolving chest-pain, for which he presented to ___ ED. He denies fevers, chills, and productive cough. In the ED, initial vitals were 99.0 ___ 24 97% 2L NC. Exam was notable for tachypneic/labored breathing, tight breath sounds. Labs were generally unremarkable with WBC 8.9 (though left shift); flu neg, neg trop/BNP, BMP and CBC wnl, lactate 1. Initial VBG 7.41/45/160 at 12:00. CXR was clear. He was given azithro, nebs, methylpred 80mg IV. Then at 1343 repeat VBG was 7.28/68/37 in the setting of increased somnolence. He was intubated for worsening hypercarbia on VBG and somnolence with fentanyl & midazolam boluses for sedation. After intubation, he triggered for HoTN to ___ systolic, was given 200mcg phenylephrine X2. He was disconnected from the vent and bagged with improvement. Vent was changed to decreased RR with I:E of 1:4. He was started on peripheral Levophed, initially at 0.2/min, and given additional fluid boluses (2 total). His vent settings when he left the ED were APV 440X10, +10, 40% FiO2. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T 98.5 HR 127 BP 116/61 100% O2 Vent: 440X15, PEEP 10, 40% FiO2 GEN: Sedated, intubated, nonresponsive to name, opens eyes to sternal rub. EYES: Pinpoint pupils, nonicteric. HEENT: elevated JVP CV: Tachycardic, regular, normal s1/s2 with no m/r/g RESP: Diminished expiratory breath sounds, no crackles/wheeze appreciated GI: Pulsatile abdomen, soft, non-tender, non-distended +BS, no masses MSK: ___ SKIN: No rashes noted NEURO: withdraws all 4 extremities to pain DISCHARGE PHYSICAL EXAM ======================== VS reviewed, see Metavision. Gen: trach in place P: Improved air movement, CTAB CV: RRR with normal S1 and S2, no m/r/g Abd: Distended, a bit firm. PEG in place Ext: Warm and well perfused Neuro: attempting to write, following commands Pertinent Results: ADMISSION LABS =============== ___ 11:54AM BLOOD WBC-8.9 RBC-4.15* Hgb-13.1* Hct-41.5 MCV-100* MCH-31.6 MCHC-31.6* RDW-13.7 RDWSD-50.7* Plt ___ ___ 11:54AM BLOOD Neuts-73.0* Lymphs-10.1* Monos-15.2* Eos-0.8* Baso-0.2 Im ___ AbsNeut-6.48* AbsLymp-0.90* AbsMono-1.35* AbsEos-0.07 AbsBaso-0.02 ___ 11:54AM BLOOD ___ PTT-30.4 ___ ___ 11:54AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-138 K-5.2 Cl-100 HCO3-25 AnGap-13 ___ 08:10PM BLOOD ALT-14 AST-16 AlkPhos-80 TotBili-0.3 ___ 11:54AM BLOOD CK-MB-7 proBNP-19 ___ 12:30PM BLOOD cTropnT-<0.01 ___ 11:54AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.7 ___ 12:16PM BLOOD pO2-150* pCO2-46* pH-7.41 calTCO2-30 Base XS-4 Comment-GREEN TOP ___ 12:16PM BLOOD Lactate-1.0 DISCHARGE LABS =============== ___ 03:37AM BLOOD WBC-11.4* RBC-2.42* Hgb-7.9* Hct-26.0* MCV-107* MCH-32.6* MCHC-30.4* RDW-16.5* RDWSD-62.4* Plt ___ ___ 03:37AM BLOOD Neuts-76.4* Lymphs-12.1* Monos-8.2 Eos-1.2 Baso-0.1 NRBC-0.4* AbsNeut-8.63* AbsLymp-1.36 AbsMono-0.92* AbsEos-0.14 AbsBaso-0.01 ___ 03:37AM BLOOD Glucose-172* UreaN-22* Creat-0.6 Na-150* K-3.4* Cl-96 HCO3-39* AnGap-15 ___ 03:37AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0 MICROBIOLOGY ============ RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S IMAGING/STUDIES =============== ___ CT SINUS/MANDIBLE/MAXIL IMPRESSION: Bilateral maxillary and sphenoid air-fluid levels which suggest acute sinusitis in the appropriate setting. ___ CT ABD & PELVIS WITH CO IMPRESSION: 1. A peg tube in appropriate location within the body of stomach. No significant intra-abdominal pathology. ___ Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. No evidence of intracranial hemorrhage. Possible acute sinusitis as described above. ___ Imaging CHEST (PORTABLE AP FINDINGS: Tracheostomy is in place. Right internal jugular catheter probably terminates where brachiocephalic veins meet to form the superior vena cava. Gastrostomy is not visualized, probably not within the field of view. Cardiac, mediastinal and hilar contours appear stable. Chest is hyperinflated. There is no pleural effusion or pneumothorax. Lungs appear clear. ___ Cardiovascular Transthoracic Echo Report The visually estimated left ventricular ejection fraction is >=75%. IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and cavity size and regional systolic function. Global function is hyperdynamic. No valvular pathology or pathologic flow identified. ___ Imaging CTA CHEST AND CT ABDOMEN IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. There is suggestion of right bronchomalacia in the current CT scan with complete collapse of the right main bronchus. Additionally bronchial wall inflammation is noted in both lower lobes with a new area of mucoid plugging to the right associated to small postobstructive atelectasis. ___ Imaging CHEST (PORTABLE AP) FINDINGS: The lungs are clear without consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. Brief Hospital Course: Mr. ___ is a ___ with a history of COPD and HTN, recent admission to ___ for hypercarbic respiratory failure from COPD exacerbation, presenting with dyspnea with hypercarbic respiratory failure secondary to COPD exacerbation, now s/p prolonged intubation and trach/PEG placement ___. TRANSITIONAL ISSUES: ==================== # Prednisone [ ] Discharged on prednisone 10 mg daily. Please continue to wean as tolerated and consider PCP prophylaxis if difficult to wean. [ ] High risk for adrenal insufficiency, has been on pred taper here and is at potential to be symptomatic # Hypernatremia [ ] Please give free water flushes 200ml q4hr. Patient could not get D5W at discharge given IV access lost # Constipation [ ] Continue aggressive bowel regimen including methylnaltrexone, and consider KUB if patient does not have bowel movement soon after arrival # Low TSH [ ] Recheck TSH, free T4 in 6 weeks as outpatient. TSH was found to be low at 0.13, likely reflecting sick euthyroid thyroid in the setting of critical illness. # Methadone [ ] Discharged on 10mg q6hrs, please continue for 2 days, then wean to 10mg q8 hours for 2 days, and then 10mg q12hrs for 2 days, and then stop. [ ] Get ECG for QTc monitoring every other day while on methadone # Seroquel [ ] Wean as tolerated ACUTE ISSUES ============ #Hypercarbic respiratory failure #Refractory COPD exacerbation The patient presented with refractory hypercarbia requiring intubation. He was initially extubated ___, but required reintubation that day for agitation/hypercarbia. He then underwent prolonged intubation for ongoing hypercarbic respiratory failure and high peak pressures. He received standing nebs, azithromycin, and multiple trials of high-dose steroids which were ultimately tapered to pred 10mg qd before discharge. The patient required heavy sedation with propofol and fentanyl as well as ketamine given low blood pressures. He received paralytics to achieve synchronization with the vent. Additionally he was given IV lasix boluses prn to keep his lungs clear from edema. His presentation was unusually severe for a COPD exacerbation and may have been partially due to overlying viral bronchiolitis or asthma leading to increased airway resistance. His course was additionally complicated by MSSA VAP (s/p 9 days cefepime transitioned to cefazolin). Despite vent adjustment to improve autoPEEP and I/E ratio, the patient required chronic intubation and was transitioned to trach on ___. He was still vent dependent transitioned to pressure support before discharge. #Encephalopathy After weaning sedation, the patient was transitioned to methadone, dilaudid, Seroquel due to concern with potential opioid withdrawal after prolonged course of fentanyl drip during intubation. He remained somnolent after this transition which was thought most likely to be iatrogenic from the opioids and Seroquel. CT head was negative. Dilaudid drip was stopped, methadone was spaced to q6hr, Seroquel was changed to qhs before discharge. #Hypotension The patient was started on norepinephrine drip for hypotension, thought to be due to vasodilatory effects from the sedatives possibly with a component of systemic inflammation from his acute respiratory failure and acidosis. #Anemia of chronic disease His hemoglobin had decreased to ___ from ___ earlier in his hospitalization. His anemia was consistent with anemia of chronic disease, likely due to systemic inflammation resulting in decreased bone marrow function and decreased production of RBCs. With increasing macrocytosis, likely representing nutritional deficiency versus reticulocyte response. #Fevers #Acute sinusitis During his second intubation, the patient developed fevers and was treated with cefazolin x 7 days for MSSA VAP. Despite appropriate treatment for MSSA with cefazolin, patient continued to spike fevers and was broadened to cefepime. He was found to have acute sinusitis on CT Head/sinus ___ and started on Unasyn with improvement in fevers, transitioned to PO augmentin before discharge. Other than positive sputum culture with MSSA and respiratory cultures showing yeast, cultures remained with no growth to date upon discharge. #Constipation CT A/P with significant stool burden. Patient was given standing bowel reg including PR bisacodyl and methylnaltrexone for prolonged opioid course. # Code Status: Full confirmed # Emergency Contact: HCP ___, Sister ___ This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 20 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Tamsulosin 0.4 mg PO QHS 4. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 4. Bisacodyl ___AILY 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 6. Heparin 5000 UNIT SC BID 7. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using HUM Insulin 8. Ipratropium Bromide Neb 1 NEB IH Q6H 9. Lactulose 30 mL PO QD:PRN Constipation - Third Line 10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 11. LORazepam 0.5 mg PO BID:PRN agitation 12. Methadone 10 mg PO Q6H Consider prescribing naloxone at discharge Tapered dose - DOWN 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Nystatin Oral Suspension 5 mL PO QID 15. Polyethylene Glycol 17 g PO DAILY 16. PredniSONE 10 mg PO DAILY Duration: 3 Days 17. QUEtiapine Fumarate 50 mg PO QHS 18. QUEtiapine Fumarate 50 mg PO QID:PRN agitation 19. Senna 8.6 mg PO BID 20. Simethicone 40-80 mg PO QID:PRN gas 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY 23. HELD- Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB This medication was held. Do not restart Albuterol Inhaler until off nebs Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Hypercarbic respiratory failure–acute on chronic COPD exacerbation SECONDARY DIAGNOSES: ===================== Hypotension Encephalopathy–toxic/metabolic Anemia of chronic disease Ventilator associated pneumonia Acute sinusitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were short of breath WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were found to have a lot of difficulty breathing which was thought to be due to your COPD - You required a breathing tube to be placed. - You were given medications to treat your COPD, including steroids, antibiotics, and breathing treatments. - You were found to have an infection in your lungs and in your sinuses, both with which were treated with antibiotics. - Because you continued to require extra breathing support with a ventilator, a tracheostomy was placed so that you could continue to receive support through the ventilator. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors ___ below) - Please maintain a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team ___ MD ___ Completed by: ___
[ "J15211", "J9622", "R578", "G92", "A419", "J440", "J95851", "E870", "J441", "J0180", "T402X5A", "T43595A", "D638", "Y848", "E0781", "Y92230", "K5900", "F17200", "I10", "T4275XA", "Z9981", "F419", "R000", "T486X5A", "E8339", "E875", "R945" ]
Allergies: Precedex Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Tracheostomy/PEG placement [MASKED] History of Present Illness: HPI: History obtained from ED and OMR as patient sedated. Mr. [MASKED] is a [MASKED] with a history of COPD, 45 pack-year smoking history, and HTN presenting with dyspnea. In [MASKED] he presented to [MASKED] for SOB and was admitted with hypercarbic respiratory failure secondary to a COPD exacerbation and influenza requiring short-term BiPAP. They were unable to wean him from O2 and he was discharged to [MASKED] on [MASKED] on 2L O2 and prednisone taper. When he arrived to rehab, the patient's dyspnea improved as did generalized weakness from his hospital stay. He then became more SOB in early [MASKED] and had an EKG concerning for ST segment changes and he was referred to the [MASKED] on [MASKED] for a cardiac evaluation. His cardiac workup there was negative (negative EKG and symptomatology felt not be anginal), and they recommended ongoing [MASKED] and smoking cessation as well as an outpatient TTE which has not been done. He then returned to rehab and subsequently developed worsening SOB, a nonproductive cough, and an episode of self-resolving chest-pain, for which he presented to [MASKED] ED. He denies fevers, chills, and productive cough. In the ED, initial vitals were 99.0 [MASKED] 24 97% 2L NC. Exam was notable for tachypneic/labored breathing, tight breath sounds. Labs were generally unremarkable with WBC 8.9 (though left shift); flu neg, neg trop/BNP, BMP and CBC wnl, lactate 1. Initial VBG 7.41/45/160 at 12:00. CXR was clear. He was given azithro, nebs, methylpred 80mg IV. Then at 1343 repeat VBG was 7.28/68/37 in the setting of increased somnolence. He was intubated for worsening hypercarbia on VBG and somnolence with fentanyl & midazolam boluses for sedation. After intubation, he triggered for HoTN to [MASKED] systolic, was given 200mcg phenylephrine X2. He was disconnected from the vent and bagged with improvement. Vent was changed to decreased RR with I:E of 1:4. He was started on peripheral Levophed, initially at 0.2/min, and given additional fluid boluses (2 total). His vent settings when he left the ED were APV 440X10, +10, 40% FiO2. Past Medical History: COPD HTN Appendectomy Social History: [MASKED] Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T 98.5 HR 127 BP 116/61 100% O2 Vent: 440X15, PEEP 10, 40% FiO2 GEN: Sedated, intubated, nonresponsive to name, opens eyes to sternal rub. EYES: Pinpoint pupils, nonicteric. HEENT: elevated JVP CV: Tachycardic, regular, normal s1/s2 with no m/r/g RESP: Diminished expiratory breath sounds, no crackles/wheeze appreciated GI: Pulsatile abdomen, soft, non-tender, non-distended +BS, no masses MSK: [MASKED] SKIN: No rashes noted NEURO: withdraws all 4 extremities to pain DISCHARGE PHYSICAL EXAM ======================== VS reviewed, see Metavision. Gen: trach in place P: Improved air movement, CTAB CV: RRR with normal S1 and S2, no m/r/g Abd: Distended, a bit firm. PEG in place Ext: Warm and well perfused Neuro: attempting to write, following commands Pertinent Results: ADMISSION LABS =============== [MASKED] 11:54AM BLOOD WBC-8.9 RBC-4.15* Hgb-13.1* Hct-41.5 MCV-100* MCH-31.6 MCHC-31.6* RDW-13.7 RDWSD-50.7* Plt [MASKED] [MASKED] 11:54AM BLOOD Neuts-73.0* Lymphs-10.1* Monos-15.2* Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-6.48* AbsLymp-0.90* AbsMono-1.35* AbsEos-0.07 AbsBaso-0.02 [MASKED] 11:54AM BLOOD [MASKED] PTT-30.4 [MASKED] [MASKED] 11:54AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-138 K-5.2 Cl-100 HCO3-25 AnGap-13 [MASKED] 08:10PM BLOOD ALT-14 AST-16 AlkPhos-80 TotBili-0.3 [MASKED] 11:54AM BLOOD CK-MB-7 proBNP-19 [MASKED] 12:30PM BLOOD cTropnT-<0.01 [MASKED] 11:54AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.7 [MASKED] 12:16PM BLOOD pO2-150* pCO2-46* pH-7.41 calTCO2-30 Base XS-4 Comment-GREEN TOP [MASKED] 12:16PM BLOOD Lactate-1.0 DISCHARGE LABS =============== [MASKED] 03:37AM BLOOD WBC-11.4* RBC-2.42* Hgb-7.9* Hct-26.0* MCV-107* MCH-32.6* MCHC-30.4* RDW-16.5* RDWSD-62.4* Plt [MASKED] [MASKED] 03:37AM BLOOD Neuts-76.4* Lymphs-12.1* Monos-8.2 Eos-1.2 Baso-0.1 NRBC-0.4* AbsNeut-8.63* AbsLymp-1.36 AbsMono-0.92* AbsEos-0.14 AbsBaso-0.01 [MASKED] 03:37AM BLOOD Glucose-172* UreaN-22* Creat-0.6 Na-150* K-3.4* Cl-96 HCO3-39* AnGap-15 [MASKED] 03:37AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0 MICROBIOLOGY ============ RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S IMAGING/STUDIES =============== [MASKED] CT SINUS/MANDIBLE/MAXIL IMPRESSION: Bilateral maxillary and sphenoid air-fluid levels which suggest acute sinusitis in the appropriate setting. [MASKED] CT ABD & PELVIS WITH CO IMPRESSION: 1. A peg tube in appropriate location within the body of stomach. No significant intra-abdominal pathology. [MASKED] Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. No evidence of intracranial hemorrhage. Possible acute sinusitis as described above. [MASKED] Imaging CHEST (PORTABLE AP FINDINGS: Tracheostomy is in place. Right internal jugular catheter probably terminates where brachiocephalic veins meet to form the superior vena cava. Gastrostomy is not visualized, probably not within the field of view. Cardiac, mediastinal and hilar contours appear stable. Chest is hyperinflated. There is no pleural effusion or pneumothorax. Lungs appear clear. [MASKED] Cardiovascular Transthoracic Echo Report The visually estimated left ventricular ejection fraction is >=75%. IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and cavity size and regional systolic function. Global function is hyperdynamic. No valvular pathology or pathologic flow identified. [MASKED] Imaging CTA CHEST AND CT ABDOMEN IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. There is suggestion of right bronchomalacia in the current CT scan with complete collapse of the right main bronchus. Additionally bronchial wall inflammation is noted in both lower lobes with a new area of mucoid plugging to the right associated to small postobstructive atelectasis. [MASKED] Imaging CHEST (PORTABLE AP) FINDINGS: The lungs are clear without consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recent admission to [MASKED] for hypercarbic respiratory failure from COPD exacerbation, presenting with dyspnea with hypercarbic respiratory failure secondary to COPD exacerbation, now s/p prolonged intubation and trach/PEG placement [MASKED]. TRANSITIONAL ISSUES: ==================== # Prednisone [ ] Discharged on prednisone 10 mg daily. Please continue to wean as tolerated and consider PCP prophylaxis if difficult to wean. [ ] High risk for adrenal insufficiency, has been on pred taper here and is at potential to be symptomatic # Hypernatremia [ ] Please give free water flushes 200ml q4hr. Patient could not get D5W at discharge given IV access lost # Constipation [ ] Continue aggressive bowel regimen including methylnaltrexone, and consider KUB if patient does not have bowel movement soon after arrival # Low TSH [ ] Recheck TSH, free T4 in 6 weeks as outpatient. TSH was found to be low at 0.13, likely reflecting sick euthyroid thyroid in the setting of critical illness. # Methadone [ ] Discharged on 10mg q6hrs, please continue for 2 days, then wean to 10mg q8 hours for 2 days, and then 10mg q12hrs for 2 days, and then stop. [ ] Get ECG for QTc monitoring every other day while on methadone # Seroquel [ ] Wean as tolerated ACUTE ISSUES ============ #Hypercarbic respiratory failure #Refractory COPD exacerbation The patient presented with refractory hypercarbia requiring intubation. He was initially extubated [MASKED], but required reintubation that day for agitation/hypercarbia. He then underwent prolonged intubation for ongoing hypercarbic respiratory failure and high peak pressures. He received standing nebs, azithromycin, and multiple trials of high-dose steroids which were ultimately tapered to pred 10mg qd before discharge. The patient required heavy sedation with propofol and fentanyl as well as ketamine given low blood pressures. He received paralytics to achieve synchronization with the vent. Additionally he was given IV lasix boluses prn to keep his lungs clear from edema. His presentation was unusually severe for a COPD exacerbation and may have been partially due to overlying viral bronchiolitis or asthma leading to increased airway resistance. His course was additionally complicated by MSSA VAP (s/p 9 days cefepime transitioned to cefazolin). Despite vent adjustment to improve autoPEEP and I/E ratio, the patient required chronic intubation and was transitioned to trach on [MASKED]. He was still vent dependent transitioned to pressure support before discharge. #Encephalopathy After weaning sedation, the patient was transitioned to methadone, dilaudid, Seroquel due to concern with potential opioid withdrawal after prolonged course of fentanyl drip during intubation. He remained somnolent after this transition which was thought most likely to be iatrogenic from the opioids and Seroquel. CT head was negative. Dilaudid drip was stopped, methadone was spaced to q6hr, Seroquel was changed to qhs before discharge. #Hypotension The patient was started on norepinephrine drip for hypotension, thought to be due to vasodilatory effects from the sedatives possibly with a component of systemic inflammation from his acute respiratory failure and acidosis. #Anemia of chronic disease His hemoglobin had decreased to [MASKED] from [MASKED] earlier in his hospitalization. His anemia was consistent with anemia of chronic disease, likely due to systemic inflammation resulting in decreased bone marrow function and decreased production of RBCs. With increasing macrocytosis, likely representing nutritional deficiency versus reticulocyte response. #Fevers #Acute sinusitis During his second intubation, the patient developed fevers and was treated with cefazolin x 7 days for MSSA VAP. Despite appropriate treatment for MSSA with cefazolin, patient continued to spike fevers and was broadened to cefepime. He was found to have acute sinusitis on CT Head/sinus [MASKED] and started on Unasyn with improvement in fevers, transitioned to PO augmentin before discharge. Other than positive sputum culture with MSSA and respiratory cultures showing yeast, cultures remained with no growth to date upon discharge. #Constipation CT A/P with significant stool burden. Patient was given standing bowel reg including PR bisacodyl and methylnaltrexone for prolonged opioid course. # Code Status: Full confirmed # Emergency Contact: HCP [MASKED], Sister [MASKED] This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 20 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Tamsulosin 0.4 mg PO QHS 4. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 4. Bisacodyl AILY 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 6. Heparin 5000 UNIT SC BID 7. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using HUM Insulin 8. Ipratropium Bromide Neb 1 NEB IH Q6H 9. Lactulose 30 mL PO QD:PRN Constipation - Third Line 10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 11. LORazepam 0.5 mg PO BID:PRN agitation 12. Methadone 10 mg PO Q6H Consider prescribing naloxone at discharge Tapered dose - DOWN 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Nystatin Oral Suspension 5 mL PO QID 15. Polyethylene Glycol 17 g PO DAILY 16. PredniSONE 10 mg PO DAILY Duration: 3 Days 17. QUEtiapine Fumarate 50 mg PO QHS 18. QUEtiapine Fumarate 50 mg PO QID:PRN agitation 19. Senna 8.6 mg PO BID 20. Simethicone 40-80 mg PO QID:PRN gas 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY 23. HELD- Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB This medication was held. Do not restart Albuterol Inhaler until off nebs Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Hypercarbic respiratory failure–acute on chronic COPD exacerbation SECONDARY DIAGNOSES: ===================== Hypotension Encephalopathy–toxic/metabolic Anemia of chronic disease Ventilator associated pneumonia Acute sinusitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were short of breath WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were found to have a lot of difficulty breathing which was thought to be due to your COPD - You required a breathing tube to be placed. - You were given medications to treat your COPD, including steroids, antibiotics, and breathing treatments. - You were found to have an infection in your lungs and in your sinuses, both with which were treated with antibiotics. - Because you continued to require extra breathing support with a ventilator, a tracheostomy was placed so that you could continue to receive support through the ventilator. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors [MASKED] below) - Please maintain a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms It was a pleasure participating in your care. We wish you the best! - Your [MASKED] Care Team [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "Y92230", "K5900", "I10", "F419" ]
[ "J15211: Pneumonia due to Methicillin susceptible Staphylococcus aureus", "J9622: Acute and chronic respiratory failure with hypercapnia", "R578: Other shock", "G92: Toxic encephalopathy", "A419: Sepsis, unspecified organism", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J95851: Ventilator associated pneumonia", "E870: Hyperosmolality and hypernatremia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J0180: Other acute sinusitis", "T402X5A: Adverse effect of other opioids, initial encounter", "T43595A: Adverse effect of other antipsychotics and neuroleptics, initial encounter", "D638: Anemia in other chronic diseases classified elsewhere", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E0781: Sick-euthyroid syndrome", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "K5900: Constipation, unspecified", "F17200: Nicotine dependence, unspecified, uncomplicated", "I10: Essential (primary) hypertension", "T4275XA: Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, initial encounter", "Z9981: Dependence on supplemental oxygen", "F419: Anxiety disorder, unspecified", "R000: Tachycardia, unspecified", "T486X5A: Adverse effect of antiasthmatics, initial encounter", "E8339: Other disorders of phosphorus metabolism", "E875: Hyperkalemia", "R945: Abnormal results of liver function studies" ]
10,049,041
25,923,317
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___ ___ Complaint: Date of ICU Admission: ___ Reason for ICU Admission: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, who re-presents from LTACH with altered mental status. Patient was recently admitted from ___ to ___ for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. The day of admission he was noted to be minimally responsive, with hypercarbia (et CO2 ___ was transferred here. In the ED, initial vitals notable for HR 110s-120s, BPs ___, RR 24. 97-100% vent/trach. Exam was notable for minimal reactivity (grimaces to noxious stimuli but does not withdraw to pain), distended abdomen, trach and PEG sites c/d/I. VBG showed pH 7.3, PCO2 88. CBC WBC 12.7, Hgb 8.7, Plts 337. LFTs 51/80. BMP notable for HCO3 of 37. BUN/Cr ___. Troponins <0.01, flu negative. CXR without focal consolidation or edema. He was placed on assist control with improvement in mental status to baseline. Patient was given vancomycin/Zosyn and 2L fluid. Due to abdominal distention, CT A/P was obtained which showed no acute process. He communicated to the ED team that people "are trying to kill me at rehab." On arrival to the MICU, the patient is awake and alert, denies pain, shortness of breath. Notes that he has been constipated. No chest pain. Mildly short of breath. No new rashes or lesions. Appears somewhat disoriented and paranoid. ROS: Positives as per HPI; otherwise negative. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: reviewed GEN: alert, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no ___ SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities DISCHARGE PHYSICAL EXAM: VS: reviewed GEN: alert + oriented, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no ___ SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities. Appears in better spirits. Pertinent Results: ADMISSION LABS =============== ___ 03:55PM BLOOD WBC-12.7* RBC-2.70* Hgb-8.7* Hct-29.1* MCV-108* MCH-32.2* MCHC-29.9* RDW-15.9* RDWSD-62.0* Plt ___ ___ 03:55PM BLOOD ___ PTT-25.8 ___ ___ 03:55PM BLOOD Glucose-148* UreaN-26* Creat-0.6 Na-142 K-4.4 Cl-91* HCO3-37* AnGap-14 ___ 03:55PM BLOOD ALT-80* AST-51* AlkPhos-101 TotBili-0.2 ___ 03:55PM BLOOD proBNP-285* ___ 03:55PM BLOOD cTropnT-<0.01 ___ 03:55PM BLOOD Lipase-16 ___ 03:55PM BLOOD Albumin-3.3* Calcium-9.7 Phos-5.5* Mg-2.1 ___ 04:02PM BLOOD ___ pO2-52* pCO2-88* pH-7.30* calTCO2-45* Base XS-12 ___ 04:02PM BLOOD Lactate-0.8 Creat-0.6 K-3.9 ___ 04:02PM BLOOD Hgb-9.1* calcHCT-27 DISCHARGE LABS =============== ___ 02:32AM BLOOD WBC-11.8* RBC-2.27* Hgb-7.3* Hct-24.7* MCV-109* MCH-32.2* MCHC-29.6* RDW-16.0* RDWSD-63.0* Plt ___ ___ 02:32AM BLOOD ___ PTT-20.8* ___ ___ 02:32AM BLOOD Glucose-87 UreaN-20 Creat-0.6 Na-140 K-3.6 Cl-91* HCO3-36* AnGap-13 ___ 02:32AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.9 IMAGING/STUDIES ================ ___ CXR: COPD/pulmonary emphysema. No focal consolidation. ___ CT Head: 1. No evidence of acute intracranial process. 2. Air-fluid levels in the sphenoid and maxillary sinuses, which can be seen with acute sinusitis in the appropriate clinical setting. Correlation with clinical circumstances is recommended. ___ CT a/p: 1. No acute findings. No findings to account for abdominal distension. 2. PEG tube in place. 3. Areas of hepatic hypodensity, not fully characterized the thought to represent benign cysts and likely focal fat deposition. Brief Hospital Course: Mr. ___ is a ___ with history of COPD, HTN, and recent admission for hypercarbic respiratory failure ___ COPD exacerbation and MSSA pneumonia, s/p trach placement ___, who presents from his LTAC with altered mental status, ultimately attributed to sedating medications. ACUTE ISSUES: # Toxic metabolic encephalopathy Initial concern for infection but ultimately, infectious work-up negative. No evidence of metabolic derangements. Ultimately contributed to sedation from home methadone. Mental status improved after this medication was held, and patient was transitioned to oxycodone PRN for pain control. CHRONIC ISSUES: # Anxiety: Continued home Seroquel at reduced dose (see discharge med list) # Acute sinusitis: Identified on CTH during prior admission. Continued agumentin (last day ___. # Constipation: Likely secondary to chronic opioid use. Continue home standing bowel regimen and also trialed methylnaltrexone with some improvement. # Pain Held home methadone on discharge, as above. Treated pain with oxycodone PRN. TRANSITIONAL ISSUES: [] Noted to have hematuria - please consider further evaluation if this continues [] Consider PJP prophylaxis given long-term steroid use [] Monitor blood sugars which were noted to be high in the setting of steroid use [] Watch out for adrenal insufficiency given long-term steroid use and recently initiated taper This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 3. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 4. Bisacodyl ___AILY 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 6. Heparin 5000 UNIT SC BID 7. Ipratropium Bromide Neb 1 NEB IH Q6H 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. LORazepam 0.5 mg PO BID:PRN agitation 10. Lactulose 30 mL PO QD:PRN Constipation - Third Line 11. Methadone 10 mg PO Q6H Tapered dose - DOWN 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Polyethylene Glycol 17 g PO DAILY 14. PredniSONE 10 mg PO DAILY 15. QUEtiapine Fumarate 50 mg PO QHS 16. QUEtiapine Fumarate 50 mg PO QID:PRN agitation 17. Senna 8.6 mg PO BID 18. Simethicone 40-80 mg PO QID:PRN gas 19. Nystatin Oral Suspension 5 mL PO QID 20. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 21. Tiotropium Bromide 1 CAP IH DAILY 22. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q6hr Disp #*5 Tablet Refills:*0 3. QUEtiapine Fumarate 25 mg PO QID:PRN agitation 4. Acetaminophen 650 mg PO Q6H 5. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 7. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 9. Bisacodyl ___AILY 10. Heparin 5000 UNIT SC BID 11. Ipratropium Bromide Neb 1 NEB IH Q6H 12. Lactulose 30 mL PO QD:PRN Constipation - Third Line 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN agitation 15. Multivitamins W/minerals 1 TAB PO DAILY 16. Nystatin Oral Suspension 5 mL PO QID 17. Polyethylene Glycol 17 g PO DAILY 18. PredniSONE 10 mg PO DAILY 19. Senna 8.6 mg PO BID 20. Simethicone 40-80 mg PO QID:PRN gas 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: - Toxic metabolic encephalopathy SECONDARY DIAGNOSIS: - Constipation - COPD - HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were admitted to the intensive care unit because you were confused. While you were in the hospital, you had imaging and labs to look for signs of infection or electrolyte disturbances. Your pain medications were adjusted and your mental status improved. We are concerned that your methadone likely contributed to your confusion, and recommend that you stop taking this medication. When you leave the hospital, you will be going to the ___ ___ facility to help work on improving your strength. Continue taking all your medications as prescribed, and follow-up with your primary care physician as needed. Followup Instructions: ___
[ "K529", "J9692", "E874", "J449", "I10", "F17210", "D72829", "F419", "Z930", "K5909" ]
Allergies: Precedex [MASKED] Complaint: Date of ICU Admission: [MASKED] Reason for ICU Admission: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure [MASKED] COPD exacerbation, MSSA Pneumonia, s/p trach placement [MASKED], who re-presents from LTACH with altered mental status. Patient was recently admitted from [MASKED] to [MASKED] for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. The day of admission he was noted to be minimally responsive, with hypercarbia (et CO2 [MASKED] was transferred here. In the ED, initial vitals notable for HR 110s-120s, BPs [MASKED], RR 24. 97-100% vent/trach. Exam was notable for minimal reactivity (grimaces to noxious stimuli but does not withdraw to pain), distended abdomen, trach and PEG sites c/d/I. VBG showed pH 7.3, PCO2 88. CBC WBC 12.7, Hgb 8.7, Plts 337. LFTs 51/80. BMP notable for HCO3 of 37. BUN/Cr [MASKED]. Troponins <0.01, flu negative. CXR without focal consolidation or edema. He was placed on assist control with improvement in mental status to baseline. Patient was given vancomycin/Zosyn and 2L fluid. Due to abdominal distention, CT A/P was obtained which showed no acute process. He communicated to the ED team that people "are trying to kill me at rehab." On arrival to the MICU, the patient is awake and alert, denies pain, shortness of breath. Notes that he has been constipated. No chest pain. Mildly short of breath. No new rashes or lesions. Appears somewhat disoriented and paranoid. ROS: Positives as per HPI; otherwise negative. Past Medical History: COPD HTN Appendectomy Social History: [MASKED] Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: reviewed GEN: alert, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no [MASKED] SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities DISCHARGE PHYSICAL EXAM: VS: reviewed GEN: alert + oriented, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no [MASKED] SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities. Appears in better spirits. Pertinent Results: ADMISSION LABS =============== [MASKED] 03:55PM BLOOD WBC-12.7* RBC-2.70* Hgb-8.7* Hct-29.1* MCV-108* MCH-32.2* MCHC-29.9* RDW-15.9* RDWSD-62.0* Plt [MASKED] [MASKED] 03:55PM BLOOD [MASKED] PTT-25.8 [MASKED] [MASKED] 03:55PM BLOOD Glucose-148* UreaN-26* Creat-0.6 Na-142 K-4.4 Cl-91* HCO3-37* AnGap-14 [MASKED] 03:55PM BLOOD ALT-80* AST-51* AlkPhos-101 TotBili-0.2 [MASKED] 03:55PM BLOOD proBNP-285* [MASKED] 03:55PM BLOOD cTropnT-<0.01 [MASKED] 03:55PM BLOOD Lipase-16 [MASKED] 03:55PM BLOOD Albumin-3.3* Calcium-9.7 Phos-5.5* Mg-2.1 [MASKED] 04:02PM BLOOD [MASKED] pO2-52* pCO2-88* pH-7.30* calTCO2-45* Base XS-12 [MASKED] 04:02PM BLOOD Lactate-0.8 Creat-0.6 K-3.9 [MASKED] 04:02PM BLOOD Hgb-9.1* calcHCT-27 DISCHARGE LABS =============== [MASKED] 02:32AM BLOOD WBC-11.8* RBC-2.27* Hgb-7.3* Hct-24.7* MCV-109* MCH-32.2* MCHC-29.6* RDW-16.0* RDWSD-63.0* Plt [MASKED] [MASKED] 02:32AM BLOOD [MASKED] PTT-20.8* [MASKED] [MASKED] 02:32AM BLOOD Glucose-87 UreaN-20 Creat-0.6 Na-140 K-3.6 Cl-91* HCO3-36* AnGap-13 [MASKED] 02:32AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.9 IMAGING/STUDIES ================ [MASKED] CXR: COPD/pulmonary emphysema. No focal consolidation. [MASKED] CT Head: 1. No evidence of acute intracranial process. 2. Air-fluid levels in the sphenoid and maxillary sinuses, which can be seen with acute sinusitis in the appropriate clinical setting. Correlation with clinical circumstances is recommended. [MASKED] CT a/p: 1. No acute findings. No findings to account for abdominal distension. 2. PEG tube in place. 3. Areas of hepatic hypodensity, not fully characterized the thought to represent benign cysts and likely focal fat deposition. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with history of COPD, HTN, and recent admission for hypercarbic respiratory failure [MASKED] COPD exacerbation and MSSA pneumonia, s/p trach placement [MASKED], who presents from his LTAC with altered mental status, ultimately attributed to sedating medications. ACUTE ISSUES: # Toxic metabolic encephalopathy Initial concern for infection but ultimately, infectious work-up negative. No evidence of metabolic derangements. Ultimately contributed to sedation from home methadone. Mental status improved after this medication was held, and patient was transitioned to oxycodone PRN for pain control. CHRONIC ISSUES: # Anxiety: Continued home Seroquel at reduced dose (see discharge med list) # Acute sinusitis: Identified on CTH during prior admission. Continued agumentin (last day [MASKED]. # Constipation: Likely secondary to chronic opioid use. Continue home standing bowel regimen and also trialed methylnaltrexone with some improvement. # Pain Held home methadone on discharge, as above. Treated pain with oxycodone PRN. TRANSITIONAL ISSUES: [] Noted to have hematuria - please consider further evaluation if this continues [] Consider PJP prophylaxis given long-term steroid use [] Monitor blood sugars which were noted to be high in the setting of steroid use [] Watch out for adrenal insufficiency given long-term steroid use and recently initiated taper This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 3. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 4. Bisacodyl AILY 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 6. Heparin 5000 UNIT SC BID 7. Ipratropium Bromide Neb 1 NEB IH Q6H 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. LORazepam 0.5 mg PO BID:PRN agitation 10. Lactulose 30 mL PO QD:PRN Constipation - Third Line 11. Methadone 10 mg PO Q6H Tapered dose - DOWN 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Polyethylene Glycol 17 g PO DAILY 14. PredniSONE 10 mg PO DAILY 15. QUEtiapine Fumarate 50 mg PO QHS 16. QUEtiapine Fumarate 50 mg PO QID:PRN agitation 17. Senna 8.6 mg PO BID 18. Simethicone 40-80 mg PO QID:PRN gas 19. Nystatin Oral Suspension 5 mL PO QID 20. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 21. Tiotropium Bromide 1 CAP IH DAILY 22. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth q6hr Disp #*5 Tablet Refills:*0 3. QUEtiapine Fumarate 25 mg PO QID:PRN agitation 4. Acetaminophen 650 mg PO Q6H 5. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 7. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 9. Bisacodyl AILY 10. Heparin 5000 UNIT SC BID 11. Ipratropium Bromide Neb 1 NEB IH Q6H 12. Lactulose 30 mL PO QD:PRN Constipation - Third Line 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN agitation 15. Multivitamins W/minerals 1 TAB PO DAILY 16. Nystatin Oral Suspension 5 mL PO QID 17. Polyethylene Glycol 17 g PO DAILY 18. PredniSONE 10 mg PO DAILY 19. Senna 8.6 mg PO BID 20. Simethicone 40-80 mg PO QID:PRN gas 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: - Toxic metabolic encephalopathy SECONDARY DIAGNOSIS: - Constipation - COPD - HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [MASKED], You were admitted to the intensive care unit because you were confused. While you were in the hospital, you had imaging and labs to look for signs of infection or electrolyte disturbances. Your pain medications were adjusted and your mental status improved. We are concerned that your methadone likely contributed to your confusion, and recommend that you stop taking this medication. When you leave the hospital, you will be going to the [MASKED] [MASKED] facility to help work on improving your strength. Continue taking all your medications as prescribed, and follow-up with your primary care physician as needed. Followup Instructions: [MASKED]
[]
[ "J449", "I10", "F17210", "F419" ]
[ "K529: Noninfective gastroenteritis and colitis, unspecified", "J9692: Respiratory failure, unspecified with hypercapnia", "E874: Mixed disorder of acid-base balance", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D72829: Elevated white blood cell count, unspecified", "F419: Anxiety disorder, unspecified", "Z930: Tracheostomy status", "K5909: Other constipation" ]
10,049,095
22,362,949
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / desipramine / verapamil Attending: ___. Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history of bipolar disease, depression, ___ disease, vascular dementia, bilateral knee replacements, peripheral neuropathy, diabetes, CKD, episodes of falls with head injury, bipolar disorder, heart block status post PPM, DVT on Coumadin, who presents with wife and son with complaint of 2 weeks of worsening mental status, anxiety, and depression. of note, he was referred to the ED from his psychiatrist for concern of worsening mood due to organic etiology. They state that he does have baseline dementia, but this is been particularly bad over the past 2 weeks. He has been very anxious and depressed. He has been complaining of pain in the lower extremities, particularly around the left heel, where he has an ulcer. He denies fevers or chills. He has not been complaining of any chest pain, shortness of breath, abdominal pain, vomiting, diarrhea, urinary symptoms. He has been eating and drinking well. His blood sugars have been well controlled at home. No recent falls. He uses a walker but is very limited in his ability to ambulate, he also uses a transfer chair at home. He does have some visiting nurse resources. Wife states that she spoke with his psychiatrist today who sent him to the emergency department. Of note, Mr. ___ follows with psychiatry here for post concussive syndrome as well as dementia related to ___ and vascular dementia. He last saw psych on ___ where his psychiatrist mentioned that the patient has had a turbulent course over the past year, characterized by episodes of falls with head injury. Mr. ___ has been confined to a wheelchair for some time and has been cared for by his extended family. His recent course has been complicated by periods of delirium, impaired cognitive status. His baseline mental status is noted to be the following: "subdued, sad faced, not overtly tearful, complaining of depression. Speech is reduced in rate, productivity. There is a paucity of thought. No evidence of spontaneous tearfulness during mental status evaluation. He appears to be somewhat disoriented, not fully oriented in all spheres." Past Medical History: Bipolar disorder ___ disease Vascular Dementia Social History: ___ Family History: Noncontributory Physical Exam: Admission Exam: General: Elderly male lying in bed, no acute distress HEENT: PERRL. EOMI. MMM. No regional lymphadenopathy. No erythema of the oropharynx. Neck: No regional lymphadenopathy or thyromegaly. Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. No hepatomegaly. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Neuro: Patient states that he is at ___. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength ___ in the lower extremities b/l). Discharge Exam: Vitals: Per OMR General: Elderly male lying in bed, no acute distress HEENT: Pupils small, reactive to light Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Pulses present by palpation bilaterally. Neuro: Patient states that he is at ___. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength ___ in the lower extremities b/l). Pertinent Results: Labs: ___ 08:55AM BLOOD WBC-6.3 RBC-5.39 Hgb-14.6 Hct-45.9 MCV-85 MCH-27.1 MCHC-31.8* RDW-15.3 RDWSD-47.3* Plt ___ ___ 06:55AM BLOOD WBC-5.2 RBC-5.26 Hgb-14.1 Hct-44.7 MCV-85 MCH-26.8 MCHC-31.5* RDW-15.5 RDWSD-47.4* Plt ___ ___ 07:15AM BLOOD WBC-4.9 RBC-5.01 Hgb-13.4* Hct-43.4 MCV-87 MCH-26.7 MCHC-30.9* RDW-15.4 RDWSD-48.6* Plt ___ ___ 07:02AM BLOOD WBC-8.5 RBC-4.99 Hgb-13.5* Hct-44.1 MCV-88 MCH-27.1 MCHC-30.6* RDW-15.3 RDWSD-49.1* Plt ___ ___ 05:59AM BLOOD WBC-4.9 RBC-4.91 Hgb-13.3* Hct-42.3 MCV-86 MCH-27.1 MCHC-31.4* RDW-15.7* RDWSD-48.9* Plt ___ ___ 06:30AM BLOOD WBC-6.3 RBC-4.78 Hgb-12.9* Hct-42.0 MCV-88 MCH-27.0 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt ___ ___ 08:55AM BLOOD Glucose-89 UreaN-34* Creat-2.4*# Na-149* K-4.4 Cl-103 HCO3-27 AnGap-19* ___ 06:55AM BLOOD Glucose-133* UreaN-35* Creat-2.4* Na-144 K-4.3 Cl-101 HCO3-27 AnGap-16 ___ 06:48AM BLOOD Glucose-117* UreaN-32* Creat-2.3* Na-150* K-4.1 Cl-107 HCO3-29 AnGap-14 ___ 07:15AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-146 K-4.2 Cl-107 HCO3-26 AnGap-13 ___ 07:02AM BLOOD Glucose-151* UreaN-29* Creat-1.8* Na-150* K-4.7 Cl-111* HCO3-28 AnGap-11 ___ 08:55AM BLOOD ALT-10 AST-19 AlkPhos-44 TotBili-0.6 ___ 06:48AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 ___ 07:02AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.1 ___ 05:59AM BLOOD Glucose-128* UreaN-32* Creat-1.7* Na-146 K-4.7 Cl-106 HCO3-29 AnGap-11 ___ 04:03PM BLOOD Glucose-119* UreaN-32* Creat-1.7* Na-143 K-4.7 Cl-104 HCO3-27 AnGap-12 ___ 06:30AM BLOOD Glucose-169* UreaN-35* Creat-1.8* Na-145 K-5.2 Cl-106 HCO3-27 AnGap-12 INR: ___ 07:20PM BLOOD ___ PTT-35.5 ___ ___ 07:15AM BLOOD ___ PTT-31.8 ___ ___ 07:02AM BLOOD ___ PTT-25.1 ___ ___ 06:30AM BLOOD ___ PTT-35.9 ___ ___ 05:59AM BLOOD ___ PTT-37.6* ___ ___ 06:30AM BLOOD ___ PTT-37.1* ___ Brief Hospital Course: ASSESSMENT/PLAN: Mr. ___ is a ___ male with history of bipolar disorder, depression, peripheral neuropathy, diabetes, CKD, who presented with 2 weeks of worsening mental status, anxiety, and depression and was found to have mild hypernatremia and and ___ that improved with hydration. Mental status also improved with correction of sodium and fluid balance. Please see below for medication changes. Acute Issues: ============ #Worsening mental status #Anxiety #Depression The patient has a ___ year history of bipolar disorder, which is characterized by periods of hypomania, irritability, but a more chronic course of depression. Psychiatry evaluated patient and got collateral from Psychiatrist Dr. ___. Psychiatry confirmed his medications as below. Acute on chronic agitation likely due to dehydration, and hypernatremia as his symptoms resolved with resolution ___ and Hypernatremia. As per Dr. ___ sertraline and donepezil was discontinued. Home ___ will be held in the setting of initiation of gabapentin to avoid over sedation. Dr. ___ will reinitiate ___ as appropriate. The patient was discharged on the following medications: -Olanzapine 2.5 mg daily -Olanzapine 2.5mg daily PRN agitation. -Trazodone 100 mg QHS -Depakote 500 mg Daily #Bilateral Lower extremity pain The patient has a history of diabetes and has a history of pain in bilateral legs. Workup inpatient has included foot XR (neg for fx), ___ dopplers (no evidence of DVT or ___ cyst). Most likely etiology either diabetic neuropathy or osteoarthritis. In coordination with outpatient psychiatrist Dr. ___ was started on gabapentin 200mg TID with good effect. #Hypernatremia ___ Cr 2.4 (previous Cr in ___ at ___ was 1.7). the creatinine improved with oral hydration. The patient should continue to drink at least four 16 oz glasses of water (64oz) a day. The hypernatremia resolved with oral hydration. He should have his CMP checked by his PCP on follow up in ___. CHRONIC ISSUES ============== #Hypertension -Continueed home amlodipine and hydrochlorothiazide #Vascular dementia Continued home ASA 81 #History of DVT -Continue home warfarin 2 mg daily #Diabetes Continued home regimen insulin Transitional Issues: ==================== [] Please check INR next appointment and make adjustments as needed [] Re-evaluation for re-initiation of ___ as well as increasing olabnzapine 2.5mg as per Dr. ___ ___ Changes: NEW: Olanzapine 2.5mg daily Olanzapine 2.5mg Daily PRN agitation Gabapenitn 200mg TID DOSE CHANGES: Depakote 500mg BID to ___ daily DISCONTINUED MEDICATIONS: Sertraline 25mg daily HELD MEDICATIONS: Lamictal 100mg daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 2.5 mg PO DAILY 2. TraZODone 100 mg PO QHS 3. Divalproex (DELayed Release) 500 mg PO BID 4. Warfarin 3 mg PO DAILY16 5. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 6. FoLIC Acid 1 mg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Thiamine 100 mg PO DAILY 11. Cyanocobalamin 1000 mcg PO DAILY 12. melatonin 3 mg oral qhs 13. Atorvastatin 20 mg PO QPM 14. LamoTRIgine 100 mg PO DAILY Discharge Medications: 1. Gabapentin 100 mg PO TID 2. OLANZapine 2.5 mg PO DAILY:PRN agitation 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Divalproex (DELayed Release) 500 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. melatonin 3 mg oral qhs 11. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 12. OLANZapine 2.5 mg PO DAILY 13. Thiamine 100 mg PO DAILY 14. TraZODone 100 mg PO QHS 15. Warfarin 3 mg PO DAILY16 16. HELD- LamoTRIgine 100 mg PO DAILY This medication was held. Do not restart LamoTRIgine until directed by Dr. ___ ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypernatremia Acute Kidney Injury 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 ___ was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - Because you were not feeling well. WHAT HAPPENED TO ME IN THE HOSPITAL? - We checked you labs and found that you were dehydrated. - We gave you fluids and your got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please drink at least four 16oz containers of water a day to prevent dehydration -Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "N179", "E870", "F05", "Z86718", "E860", "F319", "G20", "F0150", "Z950", "F419", "E1142", "I129", "E1122", "N183", "Z9181", "Z794", "Z7901", "E1165", "L89620", "R509", "Z66", "Z993", "R42", "T43595A", "Y92230", "Z87820", "Z96653" ]
Allergies: lisinopril / desipramine / verapamil Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with history of bipolar disease, depression, [MASKED] disease, vascular dementia, bilateral knee replacements, peripheral neuropathy, diabetes, CKD, episodes of falls with head injury, bipolar disorder, heart block status post PPM, DVT on Coumadin, who presents with wife and son with complaint of 2 weeks of worsening mental status, anxiety, and depression. of note, he was referred to the ED from his psychiatrist for concern of worsening mood due to organic etiology. They state that he does have baseline dementia, but this is been particularly bad over the past 2 weeks. He has been very anxious and depressed. He has been complaining of pain in the lower extremities, particularly around the left heel, where he has an ulcer. He denies fevers or chills. He has not been complaining of any chest pain, shortness of breath, abdominal pain, vomiting, diarrhea, urinary symptoms. He has been eating and drinking well. His blood sugars have been well controlled at home. No recent falls. He uses a walker but is very limited in his ability to ambulate, he also uses a transfer chair at home. He does have some visiting nurse resources. Wife states that she spoke with his psychiatrist today who sent him to the emergency department. Of note, Mr. [MASKED] follows with psychiatry here for post concussive syndrome as well as dementia related to [MASKED] and vascular dementia. He last saw psych on [MASKED] where his psychiatrist mentioned that the patient has had a turbulent course over the past year, characterized by episodes of falls with head injury. Mr. [MASKED] has been confined to a wheelchair for some time and has been cared for by his extended family. His recent course has been complicated by periods of delirium, impaired cognitive status. His baseline mental status is noted to be the following: "subdued, sad faced, not overtly tearful, complaining of depression. Speech is reduced in rate, productivity. There is a paucity of thought. No evidence of spontaneous tearfulness during mental status evaluation. He appears to be somewhat disoriented, not fully oriented in all spheres." Past Medical History: Bipolar disorder [MASKED] disease Vascular Dementia Social History: [MASKED] Family History: Noncontributory Physical Exam: Admission Exam: General: Elderly male lying in bed, no acute distress HEENT: PERRL. EOMI. MMM. No regional lymphadenopathy. No erythema of the oropharynx. Neck: No regional lymphadenopathy or thyromegaly. Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. No hepatomegaly. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Neuro: Patient states that he is at [MASKED]. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength [MASKED] in the lower extremities b/l). Discharge Exam: Vitals: Per OMR General: Elderly male lying in bed, no acute distress HEENT: Pupils small, reactive to light Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Pulses present by palpation bilaterally. Neuro: Patient states that he is at [MASKED]. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength [MASKED] in the lower extremities b/l). Pertinent Results: Labs: [MASKED] 08:55AM BLOOD WBC-6.3 RBC-5.39 Hgb-14.6 Hct-45.9 MCV-85 MCH-27.1 MCHC-31.8* RDW-15.3 RDWSD-47.3* Plt [MASKED] [MASKED] 06:55AM BLOOD WBC-5.2 RBC-5.26 Hgb-14.1 Hct-44.7 MCV-85 MCH-26.8 MCHC-31.5* RDW-15.5 RDWSD-47.4* Plt [MASKED] [MASKED] 07:15AM BLOOD WBC-4.9 RBC-5.01 Hgb-13.4* Hct-43.4 MCV-87 MCH-26.7 MCHC-30.9* RDW-15.4 RDWSD-48.6* Plt [MASKED] [MASKED] 07:02AM BLOOD WBC-8.5 RBC-4.99 Hgb-13.5* Hct-44.1 MCV-88 MCH-27.1 MCHC-30.6* RDW-15.3 RDWSD-49.1* Plt [MASKED] [MASKED] 05:59AM BLOOD WBC-4.9 RBC-4.91 Hgb-13.3* Hct-42.3 MCV-86 MCH-27.1 MCHC-31.4* RDW-15.7* RDWSD-48.9* Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-6.3 RBC-4.78 Hgb-12.9* Hct-42.0 MCV-88 MCH-27.0 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt [MASKED] [MASKED] 08:55AM BLOOD Glucose-89 UreaN-34* Creat-2.4*# Na-149* K-4.4 Cl-103 HCO3-27 AnGap-19* [MASKED] 06:55AM BLOOD Glucose-133* UreaN-35* Creat-2.4* Na-144 K-4.3 Cl-101 HCO3-27 AnGap-16 [MASKED] 06:48AM BLOOD Glucose-117* UreaN-32* Creat-2.3* Na-150* K-4.1 Cl-107 HCO3-29 AnGap-14 [MASKED] 07:15AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-146 K-4.2 Cl-107 HCO3-26 AnGap-13 [MASKED] 07:02AM BLOOD Glucose-151* UreaN-29* Creat-1.8* Na-150* K-4.7 Cl-111* HCO3-28 AnGap-11 [MASKED] 08:55AM BLOOD ALT-10 AST-19 AlkPhos-44 TotBili-0.6 [MASKED] 06:48AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 [MASKED] 07:02AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.1 [MASKED] 05:59AM BLOOD Glucose-128* UreaN-32* Creat-1.7* Na-146 K-4.7 Cl-106 HCO3-29 AnGap-11 [MASKED] 04:03PM BLOOD Glucose-119* UreaN-32* Creat-1.7* Na-143 K-4.7 Cl-104 HCO3-27 AnGap-12 [MASKED] 06:30AM BLOOD Glucose-169* UreaN-35* Creat-1.8* Na-145 K-5.2 Cl-106 HCO3-27 AnGap-12 INR: [MASKED] 07:20PM BLOOD [MASKED] PTT-35.5 [MASKED] [MASKED] 07:15AM BLOOD [MASKED] PTT-31.8 [MASKED] [MASKED] 07:02AM BLOOD [MASKED] PTT-25.1 [MASKED] [MASKED] 06:30AM BLOOD [MASKED] PTT-35.9 [MASKED] [MASKED] 05:59AM BLOOD [MASKED] PTT-37.6* [MASKED] [MASKED] 06:30AM BLOOD [MASKED] PTT-37.1* [MASKED] Brief Hospital Course: ASSESSMENT/PLAN: Mr. [MASKED] is a [MASKED] male with history of bipolar disorder, depression, peripheral neuropathy, diabetes, CKD, who presented with 2 weeks of worsening mental status, anxiety, and depression and was found to have mild hypernatremia and and [MASKED] that improved with hydration. Mental status also improved with correction of sodium and fluid balance. Please see below for medication changes. Acute Issues: ============ #Worsening mental status #Anxiety #Depression The patient has a [MASKED] year history of bipolar disorder, which is characterized by periods of hypomania, irritability, but a more chronic course of depression. Psychiatry evaluated patient and got collateral from Psychiatrist Dr. [MASKED]. Psychiatry confirmed his medications as below. Acute on chronic agitation likely due to dehydration, and hypernatremia as his symptoms resolved with resolution [MASKED] and Hypernatremia. As per Dr. [MASKED] sertraline and donepezil was discontinued. Home [MASKED] will be held in the setting of initiation of gabapentin to avoid over sedation. Dr. [MASKED] will reinitiate [MASKED] as appropriate. The patient was discharged on the following medications: -Olanzapine 2.5 mg daily -Olanzapine 2.5mg daily PRN agitation. -Trazodone 100 mg QHS -Depakote 500 mg Daily #Bilateral Lower extremity pain The patient has a history of diabetes and has a history of pain in bilateral legs. Workup inpatient has included foot XR (neg for fx), [MASKED] dopplers (no evidence of DVT or [MASKED] cyst). Most likely etiology either diabetic neuropathy or osteoarthritis. In coordination with outpatient psychiatrist Dr. [MASKED] was started on gabapentin 200mg TID with good effect. #Hypernatremia [MASKED] Cr 2.4 (previous Cr in [MASKED] at [MASKED] was 1.7). the creatinine improved with oral hydration. The patient should continue to drink at least four 16 oz glasses of water (64oz) a day. The hypernatremia resolved with oral hydration. He should have his CMP checked by his PCP on follow up in [MASKED]. CHRONIC ISSUES ============== #Hypertension -Continueed home amlodipine and hydrochlorothiazide #Vascular dementia Continued home ASA 81 #History of DVT -Continue home warfarin 2 mg daily #Diabetes Continued home regimen insulin Transitional Issues: ==================== [] Please check INR next appointment and make adjustments as needed [] Re-evaluation for re-initiation of [MASKED] as well as increasing olabnzapine 2.5mg as per Dr. [MASKED] [MASKED] Changes: NEW: Olanzapine 2.5mg daily Olanzapine 2.5mg Daily PRN agitation Gabapenitn 200mg TID DOSE CHANGES: Depakote 500mg BID to [MASKED] daily DISCONTINUED MEDICATIONS: Sertraline 25mg daily HELD MEDICATIONS: Lamictal 100mg daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 2.5 mg PO DAILY 2. TraZODone 100 mg PO QHS 3. Divalproex (DELayed Release) 500 mg PO BID 4. Warfarin 3 mg PO DAILY16 5. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 6. FoLIC Acid 1 mg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Thiamine 100 mg PO DAILY 11. Cyanocobalamin 1000 mcg PO DAILY 12. melatonin 3 mg oral qhs 13. Atorvastatin 20 mg PO QPM 14. LamoTRIgine 100 mg PO DAILY Discharge Medications: 1. Gabapentin 100 mg PO TID 2. OLANZapine 2.5 mg PO DAILY:PRN agitation 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Divalproex (DELayed Release) 500 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. melatonin 3 mg oral qhs 11. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 12. OLANZapine 2.5 mg PO DAILY 13. Thiamine 100 mg PO DAILY 14. TraZODone 100 mg PO QHS 15. Warfarin 3 mg PO DAILY16 16. HELD- LamoTRIgine 100 mg PO DAILY This medication was held. Do not restart LamoTRIgine until directed by Dr. [MASKED] [MASKED] Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Hypernatremia Acute Kidney Injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED] was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - Because you were not feeling well. WHAT HAPPENED TO ME IN THE HOSPITAL? - We checked you labs and found that you were dehydrated. - We gave you fluids and your got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please drink at least four 16oz containers of water a day to prevent dehydration -Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "Z86718", "F419", "I129", "E1122", "Z794", "Z7901", "E1165", "Z66", "Y92230" ]
[ "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "F05: Delirium due to known physiological condition", "Z86718: Personal history of other venous thrombosis and embolism", "E860: Dehydration", "F319: Bipolar disorder, unspecified", "G20: Parkinson's disease", "F0150: Vascular dementia without behavioral disturbance", "Z950: Presence of cardiac pacemaker", "F419: Anxiety disorder, unspecified", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z9181: History of falling", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "E1165: Type 2 diabetes mellitus with hyperglycemia", "L89620: Pressure ulcer of left heel, unstageable", "R509: Fever, unspecified", "Z66: Do not resuscitate", "Z993: Dependence on wheelchair", "R42: Dizziness and giddiness", "T43595A: Adverse effect of other antipsychotics and neuroleptics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z87820: Personal history of traumatic brain injury", "Z96653: Presence of artificial knee joint, bilateral" ]
10,049,334
24,032,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: hip fracture Major Surgical or Invasive Procedure: Orthopedic Surgery ___: Intramedullary nailing with a long TFN System, 10 x ___ mm, with 105 mm lag screw. History of Present Illness: ___ with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall. The patient was unable to provide history due to very poor mental status. In discussion with the patient's daughter-in-law, the patient is reported to have poor mental status at baseline. He has moments of lucidity but often he has difficulty carrying on conversation or following basic instructions. He does ambulate at baseline. He is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. He was in the living room with his wife when he had a fall. It was only witnessed by his wife, but his daughter-in-law says that it appeared he most likely was turning and tripped, falling next to a table that he tried to grab as he landed close to it. In the ED, initial vitals were: 98.7 68 186/100 16 93% RA. Exam was notable for: "Tender over right hip and femur only. right leg mildly rotated, no appreciable limb length shortening." Labs notable for Hgb 9.6 (from baseline ___, and CXR notable for moderate pulmonary edema. Hip XR showed R intertrochanteric fracture. Patient received: IV Furosemide 20 mg, IV Morphine Sulfate 2.5 mg x2. Orthopedics was consulted and recommended operative management. He was admitted to medicine for optimization of volume status. Vitals prior to transfer were: 79 163/97 16 96% Nasal Cannula. On arrival to the floor, patient was not interactive or conversant. Past Medical History: - Atrial fibrillation not on warfarin - Hypertension - Hyperlipidemia - BPH (benign prostatic hyperplasia) - Gout - History of traumatic subdural hemorrhage s/p evacuation - Peripheral neuropathy - Osteoarthritis - Non-convulsive status epilepticus - History of Clostridium difficile infection - Urinary tract infection - Edema - Congestive heart failure - Urinary incontinence - Bullous disorder Social History: ___ Family History: Unable to be obtained due to patient's mental status. Physical Exam: ADMISSION Vitals: 99.4 133-180/72-100 68-107 18 96% on 2L Gen: Elderly gentleman lying in bed, asleep but rousable to sternal rub, does not follow commands HEENT: PERRL, pupils contracted 3mm to 2mm, head appears atraumatic Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 6-7 cm above clavicle Cardiac: RRR, normal S1 and S2, no murmurs Pul: CTAB, no wheezes or crackles Abd: +BS, soft, non-tender, non-distended Ext: warm, well perfused, +RLE 1+ pitting edema to knee, RLE foreshortened and externally rotated Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Patient does not follow commands, resists passive extension of all extremities. DISCHARGE VS 98.0 143 83 18 98/ra Gen: elderly, chronically ill, NAD HEENT: EOMI, MMM Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 5cm above clavicle Cardiac: RRR, NMRG Pul: Anterior crackles to midlung, improved from yesterday. Breathing comfortably. NC in place. Abd: soft, ntnd Ext: wwp. +RLE 1+ pitting edema to knee Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Alert. Nonverbal. Does not follow commands, resists passive extension of all extremities. Pertinent Results: ====================== LABS ====================== Admission: ___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___ ___ 04:00PM BLOOD ___ PTT-30.4 ___ ___ 04:00PM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 ___ 07:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2 H/H trend: ___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___ ___ 07:00AM BLOOD WBC-7.1 RBC-2.76* Hgb-8.8* Hct-27.0* MCV-98 MCH-31.9 MCHC-32.6 RDW-14.1 RDWSD-49.6* Plt ___ ___ 05:21AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.0* Hct-24.9* MCV-97 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-50.5* Plt ___ ___ 10:28AM BLOOD WBC-11.7*# RBC-2.70* Hgb-8.4* Hct-27.5* MCV-102* MCH-31.1 MCHC-30.5* RDW-14.3 RDWSD-53.1* Plt ___ ___ 06:57AM BLOOD WBC-6.1 RBC-2.23* Hgb-7.0* Hct-22.3* MCV-100* MCH-31.4 MCHC-31.4* RDW-14.4 RDWSD-51.6* Plt ___ ___ 07:35PM BLOOD WBC-6.2 RBC-2.56* Hgb-7.9* Hct-25.2* MCV-98 MCH-30.9 MCHC-31.3* RDW-15.9* RDWSD-56.5* Plt ___ ___ 07:02AM BLOOD WBC-4.6 RBC-2.41* Hgb-7.3* Hct-24.8* MCV-103* MCH-30.3 MCHC-29.4* RDW-16.1* RDWSD-60.2* Plt ___ ___ 01:28PM BLOOD WBC-4.9 RBC-2.61* Hgb-8.0* Hct-26.3* MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-57.1* Plt ___ DISCHARGE LABS: ___ 06:15AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.6* Hct-28.6* MCV-102* MCH-30.7 MCHC-30.1* RDW-15.4 RDWSD-56.9* Plt ___ ___ 06:15AM BLOOD Glucose-107* UreaN-35* Creat-0.7 Na-148* K-3.7 Cl-110* HCO3-27 AnGap-15 ___ 06:15AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.4 ====================== MICRO ====================== ___ CULTURE-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTURE-FINAL {PROTEUS MIRABILIS}INPATIENT URINE CULTURE (Final ___: PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ====================== IMAGING/STUDIES ====================== ___ LOWER EXT VEINS ___ ___ 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Right calf subcutaneous edema. ___ (PORTABLE AP) ___ ___ Previous moderate pulmonary edema has improved, moderate bilateral pleural effusions have redistributed dependently, but probably not enlarged, and nowobscure the right heart border. Opacification at the lung bases is probably a combination of atelectasis, dependent edema overlying pleural effusion. No pneumothorax. ___ UNILAT MIN 2 VIEWS ___ ___ Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. ___ EXTREMITY FLUORO ___ ___ Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. ___. Atrial fibrillation with a moderate ventricular response. Occasional ventriclar premature beats with one couplet. Left axis deviation consistent with left anterior fascicular block. Non-specific repolarization abnormalities. Possible old anteroseptal myocardial infarction. Compared to the previous tracing of ___ no change except for ventricular ectopy now present. ___ (PORTABLE AP) ___ ___ In comparison with the study of ___, there again is enlargement of the cardiac silhouette with asymmetric pulmonary edema. As previously, it would be difficult to unequivocally exclude superimposed pneumonia, especially in the absence of a lateral view. Hazy opacifications bilaterally with poor definition of the hemi diaphragms suggests layering pleural effusion with underlying compressive atelectasis. No interval change. No evidence of pneumothorax. ___. Atrial fibrillation with a moderate ventricular response. Left anterior fascicular block. Possible old anteroseptal myocardial infarction. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ the rate is slower without other significant change. ___ (AP & LAT) RIGHT ___ No acute fracture seen of the mid to distal right femur. ___ (SINGLE VIEW) ___ Prominent right greater than left perihilar is opacities worrisome for severe pulmonary edema. Asymmetric increased opacity on the right as compared to the left could be due to asymmetric pulmonary edema versus underlying infection and/ or aspiration. Pulmonary hemorrhage not excluded. Subtle posterolateral right-sided rib deformities including right fourth through seventh ribs consistent with rib fractures ; the right fourth and seventh rib fractures appear old. The right fifth and sixth rib fractures are of indeterminate age, but could be acute to subacute. Correlate with clinical history and site of point tenderness. Findings are new since ___ ___ (UNILAT 2 VIEW) W/P ___ Comminuted right intertrochanteric fracture with varus angulation of the right femoral head. Moderate to severe right hip osteoarthritic changes. ___ C-SPINE W/O CONTRAST ___ 1. No acute fracture of the cervical spine. Multi-level degenerative changes. 2. Partially imaged right greater than left pleural effusions. Pulmonary edema. ___ HEAD W/O CONTRAST ___ Some patient motion limits the exam. No definite acute intracranial process seen. ___. Baseline artifact limits the sensitivity of interpretation. The rhythm is probably atrial fibrillation with rapid ventricular response. Occasional ventricular premature contraction and aberrantly conducted complexes. Left axis deviation. Possible inferior wall myocardial infarction of indeterminate age. Poor R wave progression in leads V1-V3. Possible anteroseptal myocardial infarction of indeterminate age. Delayed R wave transition. Diffuse non-specific ST segment changes with biphasic T waves in lead V6. Cannot exclude possible myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of ___ the ventricular rate has increased by about 20 beats per minute and the lateral ST-T wave changes are slightly more pronounced. Brief Hospital Course: ___ with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall, found to have a right intertrochanteric fracture. This was repaired by orthopedic surgery. # s/p R intertrochanteric fracture: Hip was repaired ___, complicated by mild bleeding into R thigh (R more swollen than L, dopplers negative for DVT). His enoxaparin was stopped ___ and restarted ___. # Anemia: Pt developed acute blood loss anemia from bleeding into R thigh; he received 2u PRBCs and was monitored for development of compartment syndrome. His H/H stabilized, by day of discharge Hbg 8.6. # dCHF: Patient had an episode of hypoxemia in the PACU that resolved with diuresis, most likely a mild exacerbation of his diastolic CHF. He was restarted on home diuretics but then these were stopped as the patient was no longer volume overloaded and developed hypernatremia (likely secondary to poor PO intake). The patient was discharged off home Lasix, will need daily weights to determine whether these should be restarted. # Hypernatremia: Patient developed mild hypernatremia (Na on day of discharge 148) likely secondary to poor PO intake. Received mIVF of D5W. Consider need to continue D5W for hypernatremia. # UTI: Pt developed UTI, tx'ed w/ cipro 500 bid x7d, which he completed on ___. # HTN: Patient's home carvedilol was continued, lisinopril held but restarted on day of discharge given SBPs 120s-150s. # Dementia: Of note, he is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. # Malnutrition: Nutrition provided recommendations. Pt discharged on multivitamin. Likely contributing to INR of 1.3. TRANSITIONAL ISSUES: [] Please check CBC on ___. Discharge Hgb was 8.6. Transfuse for Hbg <7 [] Patient was started on enoxaparin for prophylaxis; consider continued need for this at outpatient follow up appointment. [] F/u with orthopedics scheduled for ___. [] Patient's home diuretics (Lasix 40 mg PO BID) were held in the setting of hypernatremia. Please weigh the patient daily to assess need to restart diuretics. Weight on ___: 71.67 kgs [] The patient's sodium on day of discharge was 148 (likely secondary to poor PO intake) and he was given D5W; please check sodium regularly (every other day or so) and give D5W at a slow rate PRN for hypernatremia. [] Patient with minor coagulopathy (INR 1.3 on day of discharge) likely secondary to malnutrition, consider nutritional supplements. Pt started on multivitamin. [] Patient's home BP lisinopril was restarted on day of discharge; SBPs were 120s-150s and he had normal renal function and normal K. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Potassium Chloride 10 mEq PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Carvedilol 12.5 mg PO BID 4. Furosemide 40 mg PO BID 5. Terbinafine 1% Cream 1 Appl TP DAILY Discharge Medications: 1. Carvedilol 12.5 mg PO BID 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Lactulose ___ mL PO BID:PRN constipation 5. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 6. Acetaminophen 1000 mg PO TID Pain 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 30 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - R hip fracture - acute blood loss anemia - diastolic CHF, acute on chronic - UTI, complicated - ___ Secondary: - coagulopathy - malnutrition - advanced dementia - hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were seen at ___ for hip fracture. This was repaired by orthopedic surgery, and we gave you blood to treat some expected postsurgical thigh bleeding. Please see your appointments and medications below. You have a follow up appointment with orthopedic surgery. Sincerely, Your ___ Medicine Team Followup Instructions: ___
[ "S72141A", "I5033", "G92", "J9692", "J9691", "N179", "E870", "E872", "I4891", "E46", "D688", "D62", "L100", "N390", "W1830XA", "Y92009", "F0390", "I10", "I2510", "Z87820", "Z751", "B964", "E785", "Z66", "N401", "N39498", "R159", "S40819A", "M1611", "Z6825" ]
Allergies: Penicillins Chief Complaint: hip fracture Major Surgical or Invasive Procedure: Orthopedic Surgery [MASKED]: Intramedullary nailing with a long TFN System, 10 x [MASKED] mm, with 105 mm lag screw. History of Present Illness: [MASKED] with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall. The patient was unable to provide history due to very poor mental status. In discussion with the patient's daughter-in-law, the patient is reported to have poor mental status at baseline. He has moments of lucidity but often he has difficulty carrying on conversation or following basic instructions. He does ambulate at baseline. He is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. He was in the living room with his wife when he had a fall. It was only witnessed by his wife, but his daughter-in-law says that it appeared he most likely was turning and tripped, falling next to a table that he tried to grab as he landed close to it. In the ED, initial vitals were: 98.7 68 186/100 16 93% RA. Exam was notable for: "Tender over right hip and femur only. right leg mildly rotated, no appreciable limb length shortening." Labs notable for Hgb 9.6 (from baseline [MASKED], and CXR notable for moderate pulmonary edema. Hip XR showed R intertrochanteric fracture. Patient received: IV Furosemide 20 mg, IV Morphine Sulfate 2.5 mg x2. Orthopedics was consulted and recommended operative management. He was admitted to medicine for optimization of volume status. Vitals prior to transfer were: 79 163/97 16 96% Nasal Cannula. On arrival to the floor, patient was not interactive or conversant. Past Medical History: - Atrial fibrillation not on warfarin - Hypertension - Hyperlipidemia - BPH (benign prostatic hyperplasia) - Gout - History of traumatic subdural hemorrhage s/p evacuation - Peripheral neuropathy - Osteoarthritis - Non-convulsive status epilepticus - History of Clostridium difficile infection - Urinary tract infection - Edema - Congestive heart failure - Urinary incontinence - Bullous disorder Social History: [MASKED] Family History: Unable to be obtained due to patient's mental status. Physical Exam: ADMISSION Vitals: 99.4 133-180/72-100 68-107 18 96% on 2L Gen: Elderly gentleman lying in bed, asleep but rousable to sternal rub, does not follow commands HEENT: PERRL, pupils contracted 3mm to 2mm, head appears atraumatic Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 6-7 cm above clavicle Cardiac: RRR, normal S1 and S2, no murmurs Pul: CTAB, no wheezes or crackles Abd: +BS, soft, non-tender, non-distended Ext: warm, well perfused, +RLE 1+ pitting edema to knee, RLE foreshortened and externally rotated Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Patient does not follow commands, resists passive extension of all extremities. DISCHARGE VS 98.0 143 83 18 98/ra Gen: elderly, chronically ill, NAD HEENT: EOMI, MMM Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 5cm above clavicle Cardiac: RRR, NMRG Pul: Anterior crackles to midlung, improved from yesterday. Breathing comfortably. NC in place. Abd: soft, ntnd Ext: wwp. +RLE 1+ pitting edema to knee Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Alert. Nonverbal. Does not follow commands, resists passive extension of all extremities. Pertinent Results: ====================== LABS ====================== Admission: [MASKED] 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt [MASKED] [MASKED] 04:00PM BLOOD [MASKED] PTT-30.4 [MASKED] [MASKED] 04:00PM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 [MASKED] 07:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2 H/H trend: [MASKED] 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-7.1 RBC-2.76* Hgb-8.8* Hct-27.0* MCV-98 MCH-31.9 MCHC-32.6 RDW-14.1 RDWSD-49.6* Plt [MASKED] [MASKED] 05:21AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.0* Hct-24.9* MCV-97 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-50.5* Plt [MASKED] [MASKED] 10:28AM BLOOD WBC-11.7*# RBC-2.70* Hgb-8.4* Hct-27.5* MCV-102* MCH-31.1 MCHC-30.5* RDW-14.3 RDWSD-53.1* Plt [MASKED] [MASKED] 06:57AM BLOOD WBC-6.1 RBC-2.23* Hgb-7.0* Hct-22.3* MCV-100* MCH-31.4 MCHC-31.4* RDW-14.4 RDWSD-51.6* Plt [MASKED] [MASKED] 07:35PM BLOOD WBC-6.2 RBC-2.56* Hgb-7.9* Hct-25.2* MCV-98 MCH-30.9 MCHC-31.3* RDW-15.9* RDWSD-56.5* Plt [MASKED] [MASKED] 07:02AM BLOOD WBC-4.6 RBC-2.41* Hgb-7.3* Hct-24.8* MCV-103* MCH-30.3 MCHC-29.4* RDW-16.1* RDWSD-60.2* Plt [MASKED] [MASKED] 01:28PM BLOOD WBC-4.9 RBC-2.61* Hgb-8.0* Hct-26.3* MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-57.1* Plt [MASKED] DISCHARGE LABS: [MASKED] 06:15AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.6* Hct-28.6* MCV-102* MCH-30.7 MCHC-30.1* RDW-15.4 RDWSD-56.9* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-107* UreaN-35* Creat-0.7 Na-148* K-3.7 Cl-110* HCO3-27 AnGap-15 [MASKED] 06:15AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.4 ====================== MICRO ====================== [MASKED] CULTURE-PENDINGINPATIENT [MASKED] CULTUREBlood Culture, Routine-PENDINGINPATIENT [MASKED] CULTUREBlood Culture, Routine-PENDINGINPATIENT [MASKED] CULTURE-FINAL {PROTEUS MIRABILIS}INPATIENT URINE CULTURE (Final [MASKED]: PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ====================== IMAGING/STUDIES ====================== [MASKED] LOWER EXT VEINS [MASKED] [MASKED] 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Right calf subcutaneous edema. [MASKED] (PORTABLE AP) [MASKED] [MASKED] Previous moderate pulmonary edema has improved, moderate bilateral pleural effusions have redistributed dependently, but probably not enlarged, and nowobscure the right heart border. Opacification at the lung bases is probably a combination of atelectasis, dependent edema overlying pleural effusion. No pneumothorax. [MASKED] UNILAT MIN 2 VIEWS [MASKED] [MASKED] Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. [MASKED] EXTREMITY FLUORO [MASKED] [MASKED] Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. [MASKED]. Atrial fibrillation with a moderate ventricular response. Occasional ventriclar premature beats with one couplet. Left axis deviation consistent with left anterior fascicular block. Non-specific repolarization abnormalities. Possible old anteroseptal myocardial infarction. Compared to the previous tracing of [MASKED] no change except for ventricular ectopy now present. [MASKED] (PORTABLE AP) [MASKED] [MASKED] In comparison with the study of [MASKED], there again is enlargement of the cardiac silhouette with asymmetric pulmonary edema. As previously, it would be difficult to unequivocally exclude superimposed pneumonia, especially in the absence of a lateral view. Hazy opacifications bilaterally with poor definition of the hemi diaphragms suggests layering pleural effusion with underlying compressive atelectasis. No interval change. No evidence of pneumothorax. [MASKED]. Atrial fibrillation with a moderate ventricular response. Left anterior fascicular block. Possible old anteroseptal myocardial infarction. Non-specific repolarization abnormalities. Compared to the previous tracing of [MASKED] the rate is slower without other significant change. [MASKED] (AP & LAT) RIGHT [MASKED] No acute fracture seen of the mid to distal right femur. [MASKED] (SINGLE VIEW) [MASKED] Prominent right greater than left perihilar is opacities worrisome for severe pulmonary edema. Asymmetric increased opacity on the right as compared to the left could be due to asymmetric pulmonary edema versus underlying infection and/ or aspiration. Pulmonary hemorrhage not excluded. Subtle posterolateral right-sided rib deformities including right fourth through seventh ribs consistent with rib fractures ; the right fourth and seventh rib fractures appear old. The right fifth and sixth rib fractures are of indeterminate age, but could be acute to subacute. Correlate with clinical history and site of point tenderness. Findings are new since [MASKED] [MASKED] (UNILAT 2 VIEW) W/P [MASKED] Comminuted right intertrochanteric fracture with varus angulation of the right femoral head. Moderate to severe right hip osteoarthritic changes. [MASKED] C-SPINE W/O CONTRAST [MASKED] 1. No acute fracture of the cervical spine. Multi-level degenerative changes. 2. Partially imaged right greater than left pleural effusions. Pulmonary edema. [MASKED] HEAD W/O CONTRAST [MASKED] Some patient motion limits the exam. No definite acute intracranial process seen. [MASKED]. Baseline artifact limits the sensitivity of interpretation. The rhythm is probably atrial fibrillation with rapid ventricular response. Occasional ventricular premature contraction and aberrantly conducted complexes. Left axis deviation. Possible inferior wall myocardial infarction of indeterminate age. Poor R wave progression in leads V1-V3. Possible anteroseptal myocardial infarction of indeterminate age. Delayed R wave transition. Diffuse non-specific ST segment changes with biphasic T waves in lead V6. Cannot exclude possible myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of [MASKED] the ventricular rate has increased by about 20 beats per minute and the lateral ST-T wave changes are slightly more pronounced. Brief Hospital Course: [MASKED] with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall, found to have a right intertrochanteric fracture. This was repaired by orthopedic surgery. # s/p R intertrochanteric fracture: Hip was repaired [MASKED], complicated by mild bleeding into R thigh (R more swollen than L, dopplers negative for DVT). His enoxaparin was stopped [MASKED] and restarted [MASKED]. # Anemia: Pt developed acute blood loss anemia from bleeding into R thigh; he received 2u PRBCs and was monitored for development of compartment syndrome. His H/H stabilized, by day of discharge Hbg 8.6. # dCHF: Patient had an episode of hypoxemia in the PACU that resolved with diuresis, most likely a mild exacerbation of his diastolic CHF. He was restarted on home diuretics but then these were stopped as the patient was no longer volume overloaded and developed hypernatremia (likely secondary to poor PO intake). The patient was discharged off home Lasix, will need daily weights to determine whether these should be restarted. # Hypernatremia: Patient developed mild hypernatremia (Na on day of discharge 148) likely secondary to poor PO intake. Received mIVF of D5W. Consider need to continue D5W for hypernatremia. # UTI: Pt developed UTI, tx'ed w/ cipro 500 bid x7d, which he completed on [MASKED]. # HTN: Patient's home carvedilol was continued, lisinopril held but restarted on day of discharge given SBPs 120s-150s. # Dementia: Of note, he is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. # Malnutrition: Nutrition provided recommendations. Pt discharged on multivitamin. Likely contributing to INR of 1.3. TRANSITIONAL ISSUES: [] Please check CBC on [MASKED]. Discharge Hgb was 8.6. Transfuse for Hbg <7 [] Patient was started on enoxaparin for prophylaxis; consider continued need for this at outpatient follow up appointment. [] F/u with orthopedics scheduled for [MASKED]. [] Patient's home diuretics (Lasix 40 mg PO BID) were held in the setting of hypernatremia. Please weigh the patient daily to assess need to restart diuretics. Weight on [MASKED]: 71.67 kgs [] The patient's sodium on day of discharge was 148 (likely secondary to poor PO intake) and he was given D5W; please check sodium regularly (every other day or so) and give D5W at a slow rate PRN for hypernatremia. [] Patient with minor coagulopathy (INR 1.3 on day of discharge) likely secondary to malnutrition, consider nutritional supplements. Pt started on multivitamin. [] Patient's home BP lisinopril was restarted on day of discharge; SBPs were 120s-150s and he had normal renal function and normal K. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Potassium Chloride 10 mEq PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Carvedilol 12.5 mg PO BID 4. Furosemide 40 mg PO BID 5. Terbinafine 1% Cream 1 Appl TP DAILY Discharge Medications: 1. Carvedilol 12.5 mg PO BID 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Lactulose [MASKED] mL PO BID:PRN constipation 5. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 6. Acetaminophen 1000 mg PO TID Pain 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 30 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: - R hip fracture - acute blood loss anemia - diastolic CHF, acute on chronic - UTI, complicated - [MASKED] Secondary: - coagulopathy - malnutrition - advanced dementia - hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were seen at [MASKED] for hip fracture. This was repaired by orthopedic surgery, and we gave you blood to treat some expected postsurgical thigh bleeding. Please see your appointments and medications below. You have a follow up appointment with orthopedic surgery. Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "N179", "E872", "I4891", "D62", "N390", "I10", "I2510", "E785", "Z66" ]
[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "I5033: Acute on chronic diastolic (congestive) heart failure", "G92: Toxic encephalopathy", "J9692: Respiratory failure, unspecified with hypercapnia", "J9691: Respiratory failure, unspecified with hypoxia", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "E872: Acidosis", "I4891: Unspecified atrial fibrillation", "E46: Unspecified protein-calorie malnutrition", "D688: Other specified coagulation defects", "D62: Acute posthemorrhagic anemia", "L100: Pemphigus vulgaris", "N390: Urinary tract infection, site not specified", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F0390: Unspecified dementia without behavioral disturbance", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87820: Personal history of traumatic brain injury", "Z751: Person awaiting admission to adequate facility elsewhere", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "N39498: Other specified urinary incontinence", "R159: Full incontinence of feces", "S40819A: Abrasion of unspecified upper arm, initial encounter", "M1611: Unilateral primary osteoarthritis, right hip", "Z6825: Body mass index [BMI] 25.0-25.9, adult" ]
10,049,723
21,230,207
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / lisinopril / hydrocodone / doxycycline / clindamycin / cephalexin / bee sting / E-Mycin / Vicodin / Keflex Attending: ___. Chief Complaint: HD initiation Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ w/ history of CKD stage 5, T2DM c/b diabetic nephropathy and retinopathy, hypertension, CAD s/p CABG ___, and obesity who presents to ___ for scheduled admission for initiation of HD. He has had worsening renal function over the past several years and had AVF placed in ___. He had remained stable until over the past couple of months. Over that time, he has noticed becoming more fatigued. He often will lounge around during the day and often has difficulty with attention per his wife. He has also had worsening shortness of breath over the past couple of weeks, especially with ambulation. He has had chronic lower extremity edema that has worsened over this time period. He continues to make urine and has responded to po furosemide as an outpatient. He denied any nausea/vomiting, metallic taste, or Asterixis. He underwent first session of HD today for which he tolerated. He underwent HD for 2 hours with 0cc UF. Upon arrival to the floor, he has no complaints. He otherwise feels well and is ready to get through the rest of his HD sessions in order to be discharged. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: -T2DM c/b diabetic neuropathy, nephropathy, last hemoglobin A1c was 6.2% on ___ -CKD stage V -CAD s/p CABG ___ -CVA -HLD -OSA on CPAP -BPH -GERD -seasonal allergies -history of asbestosis and history of Agent Orange exposure -Right AV fistula placement Social History: ___ Family History: DM, CAD, MI, CVA, breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: T 98.1 BP 162 / 87 HR 71 RR 16 SpO2 100 on RA GENERAL: well developed male in NAD. AOx3. HEENT: NC/AT. MMM. OP clear. NECK: Supple. Difficult JVP exam due to body habitus. CARDIAC: RRR. Normal S1 and S2. No MGR. LUNGS: Non-labored respirations. Clear to auscultation bilaterally. No wheezing or rhonchi. ABDOMEN: Soft, obese, non-tender to palpation. Normoactive bowel sounds. EXTREMITIES: compression stockings on bilateral lower extremities with 2+ pitting edema NEUROLOGIC: no Asterixis, no focal neurologic deficits SKIN: no discernible rashes ACCESS: RUE AVF + bruit/thrill DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 98.0 160 / 70 72 18 97 RA GENERAL: well developed male in NAD. AOx3. HEENT: NC/AT. MMM. OP clear. NECK: Supple. Difficult JVP exam due to body habitus. CARDIAC: RRR. Normal S1 and S2. No MGR. LUNGS: Non-labored respirations. Clear to auscultation bilaterally. No wheezing or rhonchi. ABDOMEN: Soft, obese, non-tender to palpation. Normoactive bowel sounds. EXTREMITIES: bilateral lower extremities with 2+ pitting edema NEUROLOGIC: no asterixis, no focal neurologic deficits SKIN: no discernible rashes ACCESS: RUE AVF bandaged. Pertinent Results: ADMISSION LABS: ___ 12:12PM BLOOD WBC-10.2* RBC-2.79* Hgb-9.5* Hct-28.4* MCV-102* MCH-34.1* MCHC-33.5 RDW-14.7 RDWSD-53.8* Plt ___ ___ 12:12PM BLOOD Glucose-167* UreaN-84* Creat-5.6*# Na-144 K-4.5 Cl-106 HCO3-17* AnGap-21* ___ 12:12PM BLOOD Calcium-8.8 Phos-4.4 Mg-1.5* ___ 12:12PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 12:12PM BLOOD HCV Ab-NEG DISCHARGE LABS: ___ 06:13AM BLOOD WBC-9.6 RBC-2.94* Hgb-10.0* Hct-29.8* MCV-101* MCH-34.0* MCHC-33.6 RDW-14.5 RDWSD-53.3* Plt ___ ___ 06:13AM BLOOD Glucose-223* UreaN-31* Creat-3.6* Na-136 K-4.2 Cl-96 HCO3-27 AnGap-13 ___ 06:13AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 IMAGING/RESULTS: CXR ___- IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. ___ is a ___ w/ history of CKD stage 5, T2DM c/b diabetic nephropathy and retinopathy, hypertension, CAD s/p CABG ___, and obesity who presents to ___ for scheduled admission for initiation of HD. ACUTE ISSUES: # CKD stage V # HD initiation Patient with CKD in setting of diabetic nephropathy who had planned admission for HD initiation. His indication for HD is uremia, with worsening fatigue and mentation at home. He successfully under four sessions of HD during his hospitalization without issue. He remained on home calcitriol and nephrocaps. He will continue po furosemide 40mg on non-HD days. Plan to start HD as outpatient on ___ with plan to keep MWF schedule. # Hypertension Patient has history of hypertension on furosemide and metoprolol as outpatient. His BP was persistently elevated while hospitalized. He was started on amlodipine 5mg with mild improvement in BP. CHRONIC ISSUES: # IDDM. Patient managed by ___ as outpatient. He remained on home lantus 18u QPM and home Humalog ISS. # Anemia. Hgb low in setting of CKD. Stable. # Diabetic retinopathy. Continue valproic acid BID. # CAD. Continue ASA and statin. # Gout. Continue allopurinol at HD dosing. # Seasonal allergies. Continue home loratadine and Flonase. # GERD. Continue home omeprazole. TRANSITIONAL ISSUES: [ ] starting HD at ___ Dialysis Center on ___ schedule [ ] continue taking furosemide 40mg on non-dialysis days [ ] consider uptitration of amlodipine or additional anti-hypertensive agents for BP management. notably has a h/o ___ edema with nifedipine but this was not seen with amlodipine. [ ] home loratadine and allopurinol were dose adjusted for HD [ ] needs hepatitis B immunization given non-hep B immune status # CODE: full (presumed) # CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Vitamin D ___ UNIT PO 1X/WEEK (___) 6. Omeprazole 20 mg PO DAILY 7. Valproic Acid ___ mg PO Q12H 8. Loratadine 10 mg PO DAILY 9. Furosemide 40 mg PO DAILY 10. Ascorbic Acid ___ mg PO DAILY 11. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY 12. Calcitriol 0.25 mcg PO 3X/WEEK (___) 13. Viagra (sildenafil) 100 mg oral DAILY:PRN 14. Docusate Sodium 100 mg PO TID 15. Calcium Carbonate 1000 mg PO DAILY 16. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. Fluticasone Propionate NASAL 1 SPRY NU DAILY 18. ipratropium bromide 0.03 % nasal DAILY:PRN 19. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Furosemide 40 mg PO 4X/WEEK (___) 4. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Loratadine 10 mg PO EVERY OTHER DAY 6. Ascorbic Acid ___ mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Calcitriol 0.25 mcg PO 3X/WEEK (___) 10. Calcium Carbonate 1000 mg PO DAILY 11. Docusate Sodium 100 mg PO TID 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY 14. ipratropium bromide 0.03 % nasal DAILY:PRN 15. Metoprolol Succinate XL 100 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Valproic Acid ___ mg PO Q12H 19. Viagra (sildenafil) 100 mg oral DAILY:PRN 20. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Chronic Kidney Disease Hemodialysis Initiation Hypertension SECONDARY DIAGNOSES: IDDM CAD OSA Gout Seasonal allergies GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. Why were you admitted? - You were admitted to start dialysis. What happened during your hospitalization? - You started dialysis without any problems. - You were started on a new blood pressure medication. What should you do once you leave the hospital? - Please take all of your medications as prescribed. Some of the dosages of your home medications have changed since you are now on dialysis. - Please follow up with all of your physicians as noted below. Again, it was a pleasure taking care of you. All the best, Your ___ Team Followup Instructions: ___
[ "E1122", "I5032", "N186", "Z992", "Z794", "E1140", "I2510", "Z951", "G4733", "N400", "H548", "E11319", "E785", "K219", "E669", "D631", "M109", "Z87891", "I110", "Z6836" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / lisinopril / hydrocodone / doxycycline / clindamycin / cephalexin / bee sting / E-Mycin / Vicodin / Keflex Chief Complaint: HD initiation Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. [MASKED] is a [MASKED] w/ history of CKD stage 5, T2DM c/b diabetic nephropathy and retinopathy, hypertension, CAD s/p CABG [MASKED], and obesity who presents to [MASKED] for scheduled admission for initiation of HD. He has had worsening renal function over the past several years and had AVF placed in [MASKED]. He had remained stable until over the past couple of months. Over that time, he has noticed becoming more fatigued. He often will lounge around during the day and often has difficulty with attention per his wife. He has also had worsening shortness of breath over the past couple of weeks, especially with ambulation. He has had chronic lower extremity edema that has worsened over this time period. He continues to make urine and has responded to po furosemide as an outpatient. He denied any nausea/vomiting, metallic taste, or Asterixis. He underwent first session of HD today for which he tolerated. He underwent HD for 2 hours with 0cc UF. Upon arrival to the floor, he has no complaints. He otherwise feels well and is ready to get through the rest of his HD sessions in order to be discharged. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: -T2DM c/b diabetic neuropathy, nephropathy, last hemoglobin A1c was 6.2% on [MASKED] -CKD stage V -CAD s/p CABG [MASKED] -CVA -HLD -OSA on CPAP -BPH -GERD -seasonal allergies -history of asbestosis and history of Agent Orange exposure -Right AV fistula placement Social History: [MASKED] Family History: DM, CAD, MI, CVA, breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: T 98.1 BP 162 / 87 HR 71 RR 16 SpO2 100 on RA GENERAL: well developed male in NAD. AOx3. HEENT: NC/AT. MMM. OP clear. NECK: Supple. Difficult JVP exam due to body habitus. CARDIAC: RRR. Normal S1 and S2. No MGR. LUNGS: Non-labored respirations. Clear to auscultation bilaterally. No wheezing or rhonchi. ABDOMEN: Soft, obese, non-tender to palpation. Normoactive bowel sounds. EXTREMITIES: compression stockings on bilateral lower extremities with 2+ pitting edema NEUROLOGIC: no Asterixis, no focal neurologic deficits SKIN: no discernible rashes ACCESS: RUE AVF + bruit/thrill DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 98.0 160 / 70 72 18 97 RA GENERAL: well developed male in NAD. AOx3. HEENT: NC/AT. MMM. OP clear. NECK: Supple. Difficult JVP exam due to body habitus. CARDIAC: RRR. Normal S1 and S2. No MGR. LUNGS: Non-labored respirations. Clear to auscultation bilaterally. No wheezing or rhonchi. ABDOMEN: Soft, obese, non-tender to palpation. Normoactive bowel sounds. EXTREMITIES: bilateral lower extremities with 2+ pitting edema NEUROLOGIC: no asterixis, no focal neurologic deficits SKIN: no discernible rashes ACCESS: RUE AVF bandaged. Pertinent Results: ADMISSION LABS: [MASKED] 12:12PM BLOOD WBC-10.2* RBC-2.79* Hgb-9.5* Hct-28.4* MCV-102* MCH-34.1* MCHC-33.5 RDW-14.7 RDWSD-53.8* Plt [MASKED] [MASKED] 12:12PM BLOOD Glucose-167* UreaN-84* Creat-5.6*# Na-144 K-4.5 Cl-106 HCO3-17* AnGap-21* [MASKED] 12:12PM BLOOD Calcium-8.8 Phos-4.4 Mg-1.5* [MASKED] 12:12PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 12:12PM BLOOD HCV Ab-NEG DISCHARGE LABS: [MASKED] 06:13AM BLOOD WBC-9.6 RBC-2.94* Hgb-10.0* Hct-29.8* MCV-101* MCH-34.0* MCHC-33.6 RDW-14.5 RDWSD-53.3* Plt [MASKED] [MASKED] 06:13AM BLOOD Glucose-223* UreaN-31* Creat-3.6* Na-136 K-4.2 Cl-96 HCO3-27 AnGap-13 [MASKED] 06:13AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 IMAGING/RESULTS: CXR [MASKED]- IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [MASKED] is a [MASKED] w/ history of CKD stage 5, T2DM c/b diabetic nephropathy and retinopathy, hypertension, CAD s/p CABG [MASKED], and obesity who presents to [MASKED] for scheduled admission for initiation of HD. ACUTE ISSUES: # CKD stage V # HD initiation Patient with CKD in setting of diabetic nephropathy who had planned admission for HD initiation. His indication for HD is uremia, with worsening fatigue and mentation at home. He successfully under four sessions of HD during his hospitalization without issue. He remained on home calcitriol and nephrocaps. He will continue po furosemide 40mg on non-HD days. Plan to start HD as outpatient on [MASKED] with plan to keep MWF schedule. # Hypertension Patient has history of hypertension on furosemide and metoprolol as outpatient. His BP was persistently elevated while hospitalized. He was started on amlodipine 5mg with mild improvement in BP. CHRONIC ISSUES: # IDDM. Patient managed by [MASKED] as outpatient. He remained on home lantus 18u QPM and home Humalog ISS. # Anemia. Hgb low in setting of CKD. Stable. # Diabetic retinopathy. Continue valproic acid BID. # CAD. Continue ASA and statin. # Gout. Continue allopurinol at HD dosing. # Seasonal allergies. Continue home loratadine and Flonase. # GERD. Continue home omeprazole. TRANSITIONAL ISSUES: [ ] starting HD at [MASKED] Dialysis Center on [MASKED] schedule [ ] continue taking furosemide 40mg on non-dialysis days [ ] consider uptitration of amlodipine or additional anti-hypertensive agents for BP management. notably has a h/o [MASKED] edema with nifedipine but this was not seen with amlodipine. [ ] home loratadine and allopurinol were dose adjusted for HD [ ] needs hepatitis B immunization given non-hep B immune status # CODE: full (presumed) # CONTACT: [MASKED] (wife) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) 6. Omeprazole 20 mg PO DAILY 7. Valproic Acid [MASKED] mg PO Q12H 8. Loratadine 10 mg PO DAILY 9. Furosemide 40 mg PO DAILY 10. Ascorbic Acid [MASKED] mg PO DAILY 11. [MASKED] Caps (B complex with C#20-folic acid) 1 mg oral DAILY 12. Calcitriol 0.25 mcg PO 3X/WEEK ([MASKED]) 13. Viagra (sildenafil) 100 mg oral DAILY:PRN 14. Docusate Sodium 100 mg PO TID 15. Calcium Carbonate 1000 mg PO DAILY 16. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. Fluticasone Propionate NASAL 1 SPRY NU DAILY 18. ipratropium bromide 0.03 % nasal DAILY:PRN 19. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO EVERY OTHER DAY 3. Furosemide 40 mg PO 4X/WEEK ([MASKED]) 4. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Loratadine 10 mg PO EVERY OTHER DAY 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Calcitriol 0.25 mcg PO 3X/WEEK ([MASKED]) 10. Calcium Carbonate 1000 mg PO DAILY 11. Docusate Sodium 100 mg PO TID 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY 14. ipratropium bromide 0.03 % nasal DAILY:PRN 15. Metoprolol Succinate XL 100 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. [MASKED] Caps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Valproic Acid [MASKED] mg PO Q12H 19. Viagra (sildenafil) 100 mg oral DAILY:PRN 20. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Chronic Kidney Disease Hemodialysis Initiation Hypertension SECONDARY DIAGNOSES: IDDM CAD OSA Gout Seasonal allergies GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]. Why were you admitted? - You were admitted to start dialysis. What happened during your hospitalization? - You started dialysis without any problems. - You were started on a new blood pressure medication. What should you do once you leave the hospital? - Please take all of your medications as prescribed. Some of the dosages of your home medications have changed since you are now on dialysis. - Please follow up with all of your physicians as noted below. Again, it was a pleasure taking care of you. All the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E1122", "I5032", "Z794", "I2510", "Z951", "G4733", "N400", "E785", "K219", "E669", "M109", "Z87891", "I110" ]
[ "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "G4733: Obstructive sleep apnea (adult) (pediatric)", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "H548: Legal blindness, as defined in USA", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "D631: Anemia in chronic kidney disease", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence", "I110: Hypertensive heart disease with heart failure", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]
10,049,723
29,946,500
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / lisinopril / hydrocodone / doxycycline / clindamycin / cephalexin / bee sting / E-Mycin / Vicodin / Keflex Attending: ___ Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: ___ with T2DM, HTN, CHF, CAD s/p CABG ___, obesity and ESRD referred by his nephrologist for ___ with decreased UOP. He was sent in to the ED for elevated Cr of 4.2 from baseline 3.0. He was evaluated by his PCP ___ and was found to have Cr 4.9, He has been off losartan and furosemide for 48 hours. Patient reports poor appetite and increased fatigue over the past few days. Denies fevers, vomiting, diarrhea. He has been keeping up with his fluids and making an effort to drink plenty but his UOP is "about 70% of normal." In the ED, initial vital signs were: 99.7 86 115/57 16 97% RA - Exam notable for: RUE AVF - Labs were notable for Cr 4.2 from baseline 3.0, CO2 17, AG 27, H/H 11.6/34.0%, U/A with 100 Prot, otherwise bland. Flu A/B PCR negative. - Renal was consulted and recommended gentle IVF, hold ___, and admit to medicine. - Patient was given 2L NS - Vitals on transfer: 97.5 70 136/49 18 100% RA Upon arrival to the floor, the patient feels well. He reports some mild DOE but denies fever, chills, recent illness, sore throat, chest pain, peripheral edema, orthopnea, SOB at rest, abd pain, N/V/D, black or bloody stools, dysuria, hematuria, weak stream, post void fullness, focal weakness or falls. Review of Systems: Positive as per HPI Past Medical History: -T2DM c/b diabetic neuropathy, nephropathy, neuropathy -CAD s/p CABG ___ -HLD -OSA on CPAP -BPH -history of asbestosis and history of Agent Orange exposure (patient has a 14-month exposure history to Agent Orange during his time in the ___ in ___ and ___ in ___. Extensive workup was performed since his initial visit with us in light of his asbestosis and agent orange exposure. He has met with heme/onc, ID, GI and urology and was cleared by them for transplant. Social History: ___ Family History: DM, CAD, MI, CVA, breast cancer Physical Exam: ADMISSION PHYSICAL EXAM Vitals - 98.0 164/82 80 20 99% RA GENERAL: WNWD male in NAD, laying in bed HEENT: anicteric, PERRL, EOMI, MOM, OP clear NECK: supple, no LAD, no elevated JVD CARDIAC: RRR, soft HS, normal S1S2, no M/R/G LUNGS: mildly dyspneic with exertion of exam maneuvers, CTAB BACK: no CVAT ABDOMEN: obese, soft, NT/ND, NABS EXTREMITIES: WWP, chronic venous stasis changes BLE without current edema, RUE AVF with good thrill and bruit SKIN: warm, dry NEUROLOGIC: A&Ox3, CN II-XII intact, BLE numbness, ___ strength, no asterixis, gait not assessed DISCHARGE PHYSICAL EXAM Vital Signs: T 98.0 PO BP: 163 / 83 HR: 80 RR: 16 O2 sat: 95 GENERAL: no acute distress, sitting up on side of bed HEENT: mucous membranes moist CARDIAC: RRR, soft HS, normal S1S2 LUNGS: CTAB, no wheezing ABDOMEN: obese, soft, NT/ND EXTREMITIES: WWP, chronic venous stasis changes BLE without current edema, RUE AVF with good thrill and bruit SKIN: warm, dry NEUROLOGIC: A&Ox3, moves all extremities spontaneously Pertinent Results: ADMISSION LABS --------------- ___ 01:00PM BLOOD WBC-6.9 RBC-3.60* Hgb-11.6* Hct-34.0* MCV-94 MCH-32.2* MCHC-34.1 RDW-14.1 RDWSD-48.4* Plt ___ ___ 01:00PM BLOOD Neuts-45.2 ___ Monos-4.9* Eos-0.9* Baso-0.4 Im ___ AbsNeut-3.13 AbsLymp-3.23 AbsMono-0.34 AbsEos-0.06 AbsBaso-0.03 ___ 08:20AM BLOOD ___ ___ 01:00PM BLOOD Glucose-203* UreaN-99* Creat-4.2*# Na-135 K-3.8 Cl-95* HCO3-17* AnGap-27* ___ 08:20AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.9 ___ 05:02PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:02PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:02PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 05:02PM URINE Hours-RANDOM UreaN-678 Creat-113 Na-25 ___ 05:02PM URINE Mucous-RARE MICROBIOLOGY ------------- ___ 5:02 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. DISCHARGE LABS --------------- ___:11AM BLOOD WBC-6.1 RBC-3.24* Hgb-10.5* Hct-31.0* MCV-96 MCH-32.4* MCHC-33.9 RDW-14.5 RDWSD-50.5* Plt ___ ___ 07:11AM BLOOD Glucose-148* UreaN-77* Creat-3.4* Na-135 K-3.5 Cl-100 HCO3-18* AnGap-21* ___ 07:11AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ male with history of T2DM, HTN, CHF, CAD s/p CABG in ___, obesity, and CKD not on dialysis, admitted for ___ on CKD likely in the setting of poor po intake # Acute on chronic kidney injury. The patient presents with worsening Cr (4.9) in the setting of DM nephropathy. Baseline Cr is 3.0. Patient had been advised to hold his home Losartan and Lasix 48 hours prior to presentation, which continued to be held during his hospital stay. He currently has a fistula in the right upper extremity that is functional, but has not yet started dialysis. FeUrea and improvement in Cr with IVF are consistent with pre-renal azotemia. Patient denied any focal infectious symptoms and remained hemodynamically stable. Most likely etiology is significantly decreased po intake in the setting of worsening uremia. Nutrition evaluated the patient and his meals were complemented with Nepro supplements. Creatinine on discharge is 3.4. He will continue Calcium carbonate, Nephrocaps, Ascorbic acid, Vitamin D. Losartan and Lasix will be held until labs are drawn at his PCP's office and decision to restart will be based off those results. # Fever. Spiked a fever to 101.1 on ___ which resolved without Tylenol. Given that he did not endorse any infectious, focal symptoms, additional workup was deferred. He was monitored for 36 hours thereafter and remained afebrile. # Hypertension. Elevated SBPs to 150s-170s/70s-80s, likely in the setting of holding home Losartan and Lasix due to patient's ___. Per nephrology, these medications will continue to be held until patient has repeat labs drawn at his PCP's office to ensure resolution of ___. # Dysphagia. Patient reported dysphagia and odynophagia on the day prior to discharge. He was evaluated by Speech and Swallow who did not think he was at risk for aspiration. Continue to monitor at future visits. # CAD s/p CABG ___. No evidence of cardiac decompensation of heart failure. Continue Aspirin, Metoprolol, and Atorvastatin # Diabetic retinopathy. Continue Valproic acid, reportedly prescribed by his Retina specialist. Patient denies seizure history. # GERD: Continue Omeprazole. # Diabetes mellitus: Followed by ___. On home Lantus 22 units QHS. Decreased to 10 units QHS in the setting of his ___. # Allergies: Continue Loratidine prn # OSA: Continue CPAP at night # Gout: Stable. Continue Allopurinol ___ mg PO DAILY TRANSITIONAL ISSUES -------------------- ACUTE KIDNEY INJURY ON CKD: [ ]Advise repeat BMP-10 at PCP's visit before restarting Losartan and Furosemide [ ]Encourage nutritional supplementation and increased po intake as he is at risk for ___ given progression of his CKD - Concern for progression of CKD. Not candidate for hemodialysis initiation at this time, but may need to consider it in the future. Has functional RUE fistula in place - Cr on discharge: 3.4 - K on discharge: 3.5 HYPERTENSION [ ]Consider restarting Losartan and Furosemide after repeat BMP-10 - Blood pressure on discharge: 163/83 DYSPHAGIA [ ]Consider ENT follow-up if patient reports continued dysphagia. Evaluated by speech/swallow who did not think he was at risk for aspiration # Contact: Name of health care proxy: ___ Relationship: wife Phone number: ___ Cell phone: ___ # CODE: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 400 mg PO DAILY 2. Valproic Acid ___ mg PO Q12H 3. Allopurinol ___ mg PO DAILY 4. Metoprolol Succinate XL 75 mg PO DAILY 5. Docusate Sodium 100 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. insulin aspart 100 unit/mL SC sliding scale 8. insulin glargine 100 unit/mL (3 mL) subcutaneous QHS 9. Furosemide 60 mg PO QAM 10. Furosemide 40 mg PO 2PM DAILY 11. Corvite Free (mv, min cmb ___ 1.25-400-125-35 mg-mcg-mcg-mg oral DAILY 12. sildenafil 50 mg oral DAILY:PRN 13. Omeprazole 20 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Loratadine 10 mg PO DAILY:PRN runny nose 16. B complex with C#20-folic acid 1 mg oral DAILY 17. Ascorbic Acid ___ mg PO DAILY 18. Vitamin D ___ UNIT PO 1X/WEEK (WE) Discharge Medications: 1. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*2 2. Allopurinol ___ mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. B complex with C#20-folic acid 1 mg oral DAILY 7. Calcium Carbonate 400 mg PO DAILY 8. Corvite Free (mv, min cmb ___ 1.25-400-125-35 mg-mcg-mcg-mg oral DAILY 9. Docusate Sodium 100 mg PO DAILY 10. insulin aspart 100 unit/mL SC sliding scale 11. insulin glargine 100 unit/mL (3 mL) subcutaneous QHS 12. Loratadine 10 mg PO DAILY:PRN runny nose 13. Metoprolol Succinate XL 75 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. sildenafil 50 mg oral DAILY:PRN 16. Valproic Acid ___ mg PO Q12H 17. Vitamin D ___ UNIT PO 1X/WEEK (WE) 18. HELD- Furosemide 60 mg PO QAM This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 19. HELD- Furosemide 40 mg PO 2PM DAILY This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 20. HELD- Furosemide 40 mg PO 2PM DAILY This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 21.Outpatient Lab Work Please draw on ___: Na, K, Cl, HCO3, BUN, Cr, Glucose, Ca, Mg ICD-9: 585, chronic kidney disease FAX RESULTS TO: ___, Attn Dr. ___ ___ Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute on Chronic Kidney Disease due to reduced fluid intake, Hypertension Secondary diagnoses: CAD, Diabetes mellitus, OSA, GERD 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 ___ in the setting of an acute injury on your long-standing kidney disease. This can occur when you are not eating or drinking enough. We think your decreased appetite contributed to this insult as your kidney function improved with fluids. We do not think an infection caused this acute injury. You also reported difficulty swallowing food for the past few days. Our speech and swallow team evaluated you and do not think that you are at risk for choking. If you have worsening symptoms, it is important to make your PCP aware of these issues. Your Lasix and Losartan have been held given this acute kidney injury. They should continue to be held until you see your PCP or nephrologist who feel that it is safe to restart these medications. You will have labs drawn when you see your PCP ___ ___ to evaluate your kidney function. It is extremely important to keep your appetite up. You should supplement your meals with Nepro shakes (they can be purchased at the pharmacy). It is important to attend your follow-up appointments listed below! It was a pleasure taking care of you! We wish you the best! Your ___ Team Followup Instructions: ___
[ "N179", "I130", "E1121", "E1140", "I509", "I2510", "Z951", "K219", "E11319", "Z794", "G4733", "M109", "E669", "E785", "N400", "Z87891", "H548", "R509", "N184", "Z6837", "R1310" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / lisinopril / hydrocodone / doxycycline / clindamycin / cephalexin / bee sting / E-Mycin / Vicodin / Keflex Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with T2DM, HTN, CHF, CAD s/p CABG [MASKED], obesity and ESRD referred by his nephrologist for [MASKED] with decreased UOP. He was sent in to the ED for elevated Cr of 4.2 from baseline 3.0. He was evaluated by his PCP [MASKED] and was found to have Cr 4.9, He has been off losartan and furosemide for 48 hours. Patient reports poor appetite and increased fatigue over the past few days. Denies fevers, vomiting, diarrhea. He has been keeping up with his fluids and making an effort to drink plenty but his UOP is "about 70% of normal." In the ED, initial vital signs were: 99.7 86 115/57 16 97% RA - Exam notable for: RUE AVF - Labs were notable for Cr 4.2 from baseline 3.0, CO2 17, AG 27, H/H 11.6/34.0%, U/A with 100 Prot, otherwise bland. Flu A/B PCR negative. - Renal was consulted and recommended gentle IVF, hold [MASKED], and admit to medicine. - Patient was given 2L NS - Vitals on transfer: 97.5 70 136/49 18 100% RA Upon arrival to the floor, the patient feels well. He reports some mild DOE but denies fever, chills, recent illness, sore throat, chest pain, peripheral edema, orthopnea, SOB at rest, abd pain, N/V/D, black or bloody stools, dysuria, hematuria, weak stream, post void fullness, focal weakness or falls. Review of Systems: Positive as per HPI Past Medical History: -T2DM c/b diabetic neuropathy, nephropathy, neuropathy -CAD s/p CABG [MASKED] -HLD -OSA on CPAP -BPH -history of asbestosis and history of Agent Orange exposure (patient has a 14-month exposure history to Agent Orange during his time in the [MASKED] in [MASKED] and [MASKED] in [MASKED]. Extensive workup was performed since his initial visit with us in light of his asbestosis and agent orange exposure. He has met with heme/onc, ID, GI and urology and was cleared by them for transplant. Social History: [MASKED] Family History: DM, CAD, MI, CVA, breast cancer Physical Exam: ADMISSION PHYSICAL EXAM Vitals - 98.0 164/82 80 20 99% RA GENERAL: WNWD male in NAD, laying in bed HEENT: anicteric, PERRL, EOMI, MOM, OP clear NECK: supple, no LAD, no elevated JVD CARDIAC: RRR, soft HS, normal S1S2, no M/R/G LUNGS: mildly dyspneic with exertion of exam maneuvers, CTAB BACK: no CVAT ABDOMEN: obese, soft, NT/ND, NABS EXTREMITIES: WWP, chronic venous stasis changes BLE without current edema, RUE AVF with good thrill and bruit SKIN: warm, dry NEUROLOGIC: A&Ox3, CN II-XII intact, BLE numbness, [MASKED] strength, no asterixis, gait not assessed DISCHARGE PHYSICAL EXAM Vital Signs: T 98.0 PO BP: 163 / 83 HR: 80 RR: 16 O2 sat: 95 GENERAL: no acute distress, sitting up on side of bed HEENT: mucous membranes moist CARDIAC: RRR, soft HS, normal S1S2 LUNGS: CTAB, no wheezing ABDOMEN: obese, soft, NT/ND EXTREMITIES: WWP, chronic venous stasis changes BLE without current edema, RUE AVF with good thrill and bruit SKIN: warm, dry NEUROLOGIC: A&Ox3, moves all extremities spontaneously Pertinent Results: ADMISSION LABS --------------- [MASKED] 01:00PM BLOOD WBC-6.9 RBC-3.60* Hgb-11.6* Hct-34.0* MCV-94 MCH-32.2* MCHC-34.1 RDW-14.1 RDWSD-48.4* Plt [MASKED] [MASKED] 01:00PM BLOOD Neuts-45.2 [MASKED] Monos-4.9* Eos-0.9* Baso-0.4 Im [MASKED] AbsNeut-3.13 AbsLymp-3.23 AbsMono-0.34 AbsEos-0.06 AbsBaso-0.03 [MASKED] 08:20AM BLOOD [MASKED] [MASKED] 01:00PM BLOOD Glucose-203* UreaN-99* Creat-4.2*# Na-135 K-3.8 Cl-95* HCO3-17* AnGap-27* [MASKED] 08:20AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.9 [MASKED] 05:02PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 05:02PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 05:02PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 05:02PM URINE Hours-RANDOM UreaN-678 Creat-113 Na-25 [MASKED] 05:02PM URINE Mucous-RARE MICROBIOLOGY ------------- [MASKED] 5:02 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. DISCHARGE LABS --------------- [MASKED]:11AM BLOOD WBC-6.1 RBC-3.24* Hgb-10.5* Hct-31.0* MCV-96 MCH-32.4* MCHC-33.9 RDW-14.5 RDWSD-50.5* Plt [MASKED] [MASKED] 07:11AM BLOOD Glucose-148* UreaN-77* Creat-3.4* Na-135 K-3.5 Cl-100 HCO3-18* AnGap-21* [MASKED] 07:11AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of T2DM, HTN, CHF, CAD s/p CABG in [MASKED], obesity, and CKD not on dialysis, admitted for [MASKED] on CKD likely in the setting of poor po intake # Acute on chronic kidney injury. The patient presents with worsening Cr (4.9) in the setting of DM nephropathy. Baseline Cr is 3.0. Patient had been advised to hold his home Losartan and Lasix 48 hours prior to presentation, which continued to be held during his hospital stay. He currently has a fistula in the right upper extremity that is functional, but has not yet started dialysis. FeUrea and improvement in Cr with IVF are consistent with pre-renal azotemia. Patient denied any focal infectious symptoms and remained hemodynamically stable. Most likely etiology is significantly decreased po intake in the setting of worsening uremia. Nutrition evaluated the patient and his meals were complemented with Nepro supplements. Creatinine on discharge is 3.4. He will continue Calcium carbonate, Nephrocaps, Ascorbic acid, Vitamin D. Losartan and Lasix will be held until labs are drawn at his PCP's office and decision to restart will be based off those results. # Fever. Spiked a fever to 101.1 on [MASKED] which resolved without Tylenol. Given that he did not endorse any infectious, focal symptoms, additional workup was deferred. He was monitored for 36 hours thereafter and remained afebrile. # Hypertension. Elevated SBPs to 150s-170s/70s-80s, likely in the setting of holding home Losartan and Lasix due to patient's [MASKED]. Per nephrology, these medications will continue to be held until patient has repeat labs drawn at his PCP's office to ensure resolution of [MASKED]. # Dysphagia. Patient reported dysphagia and odynophagia on the day prior to discharge. He was evaluated by Speech and Swallow who did not think he was at risk for aspiration. Continue to monitor at future visits. # CAD s/p CABG [MASKED]. No evidence of cardiac decompensation of heart failure. Continue Aspirin, Metoprolol, and Atorvastatin # Diabetic retinopathy. Continue Valproic acid, reportedly prescribed by his Retina specialist. Patient denies seizure history. # GERD: Continue Omeprazole. # Diabetes mellitus: Followed by [MASKED]. On home Lantus 22 units QHS. Decreased to 10 units QHS in the setting of his [MASKED]. # Allergies: Continue Loratidine prn # OSA: Continue CPAP at night # Gout: Stable. Continue Allopurinol [MASKED] mg PO DAILY TRANSITIONAL ISSUES -------------------- ACUTE KIDNEY INJURY ON CKD: [ ]Advise repeat BMP-10 at PCP's visit before restarting Losartan and Furosemide [ ]Encourage nutritional supplementation and increased po intake as he is at risk for [MASKED] given progression of his CKD - Concern for progression of CKD. Not candidate for hemodialysis initiation at this time, but may need to consider it in the future. Has functional RUE fistula in place - Cr on discharge: 3.4 - K on discharge: 3.5 HYPERTENSION [ ]Consider restarting Losartan and Furosemide after repeat BMP-10 - Blood pressure on discharge: 163/83 DYSPHAGIA [ ]Consider ENT follow-up if patient reports continued dysphagia. Evaluated by speech/swallow who did not think he was at risk for aspiration # Contact: Name of health care proxy: [MASKED] Relationship: wife Phone number: [MASKED] Cell phone: [MASKED] # CODE: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 400 mg PO DAILY 2. Valproic Acid [MASKED] mg PO Q12H 3. Allopurinol [MASKED] mg PO DAILY 4. Metoprolol Succinate XL 75 mg PO DAILY 5. Docusate Sodium 100 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. insulin aspart 100 unit/mL SC sliding scale 8. insulin glargine 100 unit/mL (3 mL) subcutaneous QHS 9. Furosemide 60 mg PO QAM 10. Furosemide 40 mg PO 2PM DAILY 11. Corvite Free (mv, min cmb [MASKED] 1.25-400-125-35 mg-mcg-mcg-mg oral DAILY 12. sildenafil 50 mg oral DAILY:PRN 13. Omeprazole 20 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Loratadine 10 mg PO DAILY:PRN runny nose 16. B complex with C#20-folic acid 1 mg oral DAILY 17. Ascorbic Acid [MASKED] mg PO DAILY 18. Vitamin D [MASKED] UNIT PO 1X/WEEK (WE) Discharge Medications: 1. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*2 2. Allopurinol [MASKED] mg PO DAILY 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. B complex with C#20-folic acid 1 mg oral DAILY 7. Calcium Carbonate 400 mg PO DAILY 8. Corvite Free (mv, min cmb [MASKED] 1.25-400-125-35 mg-mcg-mcg-mg oral DAILY 9. Docusate Sodium 100 mg PO DAILY 10. insulin aspart 100 unit/mL SC sliding scale 11. insulin glargine 100 unit/mL (3 mL) subcutaneous QHS 12. Loratadine 10 mg PO DAILY:PRN runny nose 13. Metoprolol Succinate XL 75 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. sildenafil 50 mg oral DAILY:PRN 16. Valproic Acid [MASKED] mg PO Q12H 17. Vitamin D [MASKED] UNIT PO 1X/WEEK (WE) 18. HELD- Furosemide 60 mg PO QAM This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 19. HELD- Furosemide 40 mg PO 2PM DAILY This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 20. HELD- Furosemide 40 mg PO 2PM DAILY This medication was held. Do not restart Furosemide until you see your PCP or nephrologist 21.Outpatient Lab Work Please draw on [MASKED]: Na, K, Cl, HCO3, BUN, Cr, Glucose, Ca, Mg ICD-9: 585, chronic kidney disease FAX RESULTS TO: [MASKED], Attn Dr. [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute on Chronic Kidney Disease due to reduced fluid intake, Hypertension Secondary diagnoses: CAD, Diabetes mellitus, OSA, GERD 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] in the setting of an acute injury on your long-standing kidney disease. This can occur when you are not eating or drinking enough. We think your decreased appetite contributed to this insult as your kidney function improved with fluids. We do not think an infection caused this acute injury. You also reported difficulty swallowing food for the past few days. Our speech and swallow team evaluated you and do not think that you are at risk for choking. If you have worsening symptoms, it is important to make your PCP aware of these issues. Your Lasix and Losartan have been held given this acute kidney injury. They should continue to be held until you see your PCP or nephrologist who feel that it is safe to restart these medications. You will have labs drawn when you see your PCP [MASKED] [MASKED] to evaluate your kidney function. It is extremely important to keep your appetite up. You should supplement your meals with Nepro shakes (they can be purchased at the pharmacy). It is important to attend your follow-up appointments listed below! It was a pleasure taking care of you! We wish you the best! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "I130", "I2510", "Z951", "K219", "Z794", "G4733", "M109", "E669", "E785", "N400", "Z87891" ]
[ "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "I509: Heart failure, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "K219: Gastro-esophageal reflux disease without esophagitis", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z794: Long term (current) use of insulin", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M109: Gout, unspecified", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z87891: Personal history of nicotine dependence", "H548: Legal blindness, as defined in USA", "R509: Fever, unspecified", "N184: Chronic kidney disease, stage 4 (severe)", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "R1310: Dysphagia, unspecified" ]
10,049,746
20,432,838
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pravachol / Darvon / Ambien / Augmentin / etodolac / Corticosteroids (Glucocorticoids) / cefepime Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ line removal ___ History of Present Illness: ___ with DLBCL s/p R-CHOP, recent PE, COPD, recent periprosthetic femur fracture, hemochromatosis who presents from her assisted living with fever to 100.5F. She was noted by her rehab staff to have a fever to 100.5F, she also reports having chills which started today. She has had a dry cough for 2 weeks which she attributes to seasonal allergies, non-productive. She was discharged with a Foley after last admission, but this was removed over 1 week ago. Denies dysuria, frequency or foul smelling urine. She has had no pain at her right ___ site and didn't note any discharge. No diarrhea or abdominal pain. She recently had a long stay on the ___ service and was discharged on ___. During that time, she was found to have DLCBL and received R-CHOP chemotherapy. At admission, she also had a fracture in her left femur around her prior hip arthroplasty hardware, this was managed non-operatively. During that admission, she had one BCx from her PICC which grew CoNS and Diptheroids, this was felt to be contaminant. She was treated for febrile neutropenia with vancomycin and Zosyn->cefepime->meropenem. During that admission, she was also found to have a PE and was started on therapeutic dose Lovenox. In the ED, she had one set of BCx sent from the ___ and one peripheral. ED notes report erythema and a "small pustule" at the ___ entry site. She received IVF and vancomycin 1000mg x1. She received Tylenol at her SNF prior to arrival In the ED, despite this she had a fever to 100.8F. Tachy to the 100-110s. Currently, she feels well with no complaints. Past Medical History: Osteoarthritis Hypothyroidism Hemochromatosis Asthma HCV- resolved Basal cell ca- forehead Non-Hodgkin's lymphoma located in liver. Social History: ___ Family History: Her brother was diagnosed with kidney cancer at ___ and died shortly thereafter. Her father died of a heart attack at ___. Her mother died of coronary artery disease at ___. Her sister died of COPD and she was a heavy smoker. She otherwise denies any other history of cancer, hypertension, stroke in her family. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: Tmax 100.8 T 99.2 BP 159 / 80 HR 96 RR 20 SpO2 93 RA General: NAD HEENT: Dry MM CV: RRR, no m/r/g PULM: Fine crackles at the left base, otherwise clear ABD: BS+, soft, NT/ND EXT: warm well perfused, no edema. SKIN: No rashes or skin breakdown. RUE ___ site with erythema under taped areas, very slight erythema at the actual ___ exit site. There is a small amount of pus able to be expressed from the exit site with crusting on the dressing. NEURO: alert and oriented x 4, ___, EOMI, able to lift all extremities against resistance DISCHARGE PHYSICAL EXAM: VS: TC 97.6 103-125/52-70 ___ 91-98%RA I/O: ___ BM x1 GEN: comfortable, sitting in bed, NAD HEENT: Dry MM, OP clear CV: RRR, no m/r/g PULM: non-labored. CTA bilaterally. ABD: BS+, soft, NT/ND GU: Foley in place EXT: Trace BLE edema, no tremors. SKIN: Rash on posterior chest extending to buttocks/right leg region now resolved. Old ___ site w/o discharge or tenderness NEURO: alert and oriented x 3. ___, EOMI, able to lift all extremities against resistance ACCESS: PIV intact Pertinent Results: ADMISSION LABS: ___ 01:16PM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 01:16PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* ___ 01:16PM URINE RBC-5* WBC-163* BACTERIA-MOD* YEAST-NONE EPI-0 ___ 09:36PM ___ PTT-33.0 ___ ___ 08:13PM LACTATE-0.9 ___ 08:00PM GLUCOSE-114* UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-22 ANION GAP-17 ___ 08:00PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.8 ___ 08:00PM WBC-10.3* RBC-2.98* HGB-9.1* HCT-28.5* MCV-96 MCH-30.5 MCHC-31.9* RDW-18.4* RDWSD-64.5* ___ 08:00PM PLT COUNT-426* ___ 1:16 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 9:33 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. >100,000 CFU/mL. ___ 3:41 am CATHETER TIP-IV Source: RUE PICC. **FINAL REPORT ___ WOUND CULTURE (Final ___: No significant growth. DISCHARGE LABS: ___ 06:05AM BLOOD WBC-41.7* RBC-3.09* Hgb-9.4* Hct-29.7* MCV-96 MCH-30.4 MCHC-31.6* RDW-18.6* RDWSD-64.9* Plt ___ ___ 06:05AM BLOOD Neuts-96* Bands-0 Lymphs-1* Monos-0 Eos-3 Baso-0 ___ Myelos-0 AbsNeut-40.03* AbsLymp-0.42* AbsMono-0.00* AbsEos-1.25* AbsBaso-0.00* ___ 06:05AM BLOOD Glucose-89 UreaN-20 Creat-0.8 Na-139 K-4.9 Cl-101 HCO3-27 AnGap-11 ___ 06:05AM BLOOD ALT-14 AST-16 LD(LDH)-183 AlkPhos-109* TotBili-0.4 ___ 06:05AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.5 Mg-2.___CUTE ISSUES = = = = = = ================================================================ #E coli UTI/Pyelonephritis: She was admitted with tachypnea, fever, and AMS concerning for sepsis. She was found to have Ecoli UTI and with treatment, her symptomology improved significantly. She was initiated on cefepime and vancomycin on admission. ___ removed ___ as concerned about potential source of infection but cultures are negative. Placed foley to get UA/UCx and measure post-void residuals. Post-void residuals remained high so kept Foley in. Initiated voiding trials without success. -Discontinued vancomycin as there was no evidence of gram positive infection (___) -Initiated Cefepime (d1: ___ then she was switched to DS Bactrim (d1: ___ given rash and urine sensitivities result. She needs a 14D course of ABX total as concern of pyelonephritis on recent CT torso. Her course will complete on ___. She has an allergy to PCN; therefore, avoiding cephalosporins and ampicillin. Repeat urine culture ___ did not show evidence of Ecoli but showed > 100,000 CFU/mL of yeast, likely a contaminant given foley use so did not treat. #Urinary retention: Pt was not requiring a foley prior to this admission. Foley has been present for almost entire admission; several voiding trials during the week prior to discharge were unsuccessful. She is being discharged with a Foley catheter to rehab. This will be a transitional issue for the rehab facility to work on, and if the pt. is unable to void. She has follow up appointment with outpatient urology on ___ at 8:30AM. #Diffuse Large B- Cell Lymphoma: After discussion with primary oncologist, Dr. ___ was to initiate cycle 4 of R-mini-CHOP given that her most recent restaging imaging is consistent with marked improvement of her disease. Extensive discussion with family on ___ with SW and attending physician, ___. Patient and family agreed to initiate C4 of R-mini-CHOP. She is currently D+6 of regimen today. She continues on infectious prophylaxis with acyclovir. Atovaquone on hold given Bactrim use as above TO RESUME ONCE OFF BACTRIM. Once UTI course completes, will restart Atovaquone. Initiated GCSF support on ___ and will need to monitor CBC. #Rash: Resolved. Unclear etiology but attributed to cefepime use which was started for Ecoli UTI on admission. She has been off cefepime since ___ and the rash has since resolved, continue to monitor for recurrence outpatient. #Femoral fracture: Initially presented to an OSH w/ a left femoral fracture in the setting of a mechanical fall. Orthopedic surgery determined she could have surgery if desired but non-operative management is also appropriate. Pt. did not wish to have surgery. She continues with physical therapy in-house and is being transitioned to a rehab facility outpatient. #Psychosis: This occurred last hospitalization likely multifactorial in setting of poly-pharmacy, fever iso active infection. She responded well to zyprexa 5mg daily. This was held at discharge. #Malnutrition Risk: Concern for overall decrease in nutritional status. She makes attempt to eat but her intake remains poor. Nutrition consulted and thinks if within goals of care, may benefit from enteral feeding. Will continue to monitor outpatient. #Constipation: stooling daily, continues on bowel regimen #PE: On therapeutic Lovenox 60mg q12hrs #Hypothyroidism: continues levothyroxine. #COPD: Continue albuterol and Advair TRANSITIONAL ISSUES = = = = = = ================================================================ []Will need CBCs to monitor her blood counts. Please check them on ___ and fax results to ___, Dr. ___ ___ for monitoring. []Will need Oncology follow up w/ Dr. ___ to discuss further treatment -- this is scheduled for ___ []Please monitor platelets while the pt is on lovenox. She is on this for her pulmonary emboli. Should her plts drop to between ___, please reduce the dose in half (from 60bid to 30bid). If plts drop below 30K, please stop lovenox. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Filgrastim-sndz 300 mcg SC Q24H 2. Atovaquone Suspension 1500 mg PO DAILY 3. Enoxaparin Sodium 60 mg SC Q12H 4. Acyclovir 400 mg PO TID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD Q24H 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Multivitamins 1 TAB PO DAILY 13. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Senna 8.6 mg PO BID:PRN constipation 3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days you will continue this medication until ___ 4. Acyclovir 400 mg PO TID 5. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea 6. Enoxaparin Sodium 60 mg SC Q12H 7. Filgrastim-sndz 300 mcg SC Q24H 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD Q24H 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Montelukast 10 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. HELD- Atovaquone Suspension 1500 mg PO DAILY This medication was held. Do not restart Atovaquone Suspension until your outpatient team advises you to restart. likely restart ___ after finishing course of Bactrim for UTI. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: =================== Ecoli Bacteruria Pyelonephritis Diffuse large B cell lymphoma Secondary: ================== Femoral fracture Chronic obstructive pulmonary disease Pulmonary emboli Steroid psychosis/delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, You were admitted due to fever and found to have a urinary tract infection. You were placed on IV Antibiotics and your line was removed with improvement in your symptoms. You will continue oral antibiotics at the rehabilitation facility for a 2 week course. You also received your fourth cycle of chemotherapy (R-mini-CHOP). You tolerated this very well and will continue your daily neupogen injections until your outpatient team advises you to discontinue. You will be discharged today and follow up as stated below. It was a pleasure taking care of you. Followup Instructions: ___
[ "A419", "I2699", "C8339", "J449", "N12", "F05", "B9620", "E039", "E83119", "Z85828", "Z87891", "Z66", "S72002D", "M9702XD", "W19XXXD", "L270", "T361X5A", "Y92239", "K5900" ]
Allergies: Pravachol / Darvon / Ambien / Augmentin / etodolac / Corticosteroids (Glucocorticoids) / cefepime Chief Complaint: fever Major Surgical or Invasive Procedure: [MASKED] line removal [MASKED] History of Present Illness: [MASKED] with DLBCL s/p R-CHOP, recent PE, COPD, recent periprosthetic femur fracture, hemochromatosis who presents from her assisted living with fever to 100.5F. She was noted by her rehab staff to have a fever to 100.5F, she also reports having chills which started today. She has had a dry cough for 2 weeks which she attributes to seasonal allergies, non-productive. She was discharged with a Foley after last admission, but this was removed over 1 week ago. Denies dysuria, frequency or foul smelling urine. She has had no pain at her right [MASKED] site and didn't note any discharge. No diarrhea or abdominal pain. She recently had a long stay on the [MASKED] service and was discharged on [MASKED]. During that time, she was found to have DLCBL and received R-CHOP chemotherapy. At admission, she also had a fracture in her left femur around her prior hip arthroplasty hardware, this was managed non-operatively. During that admission, she had one BCx from her PICC which grew CoNS and Diptheroids, this was felt to be contaminant. She was treated for febrile neutropenia with vancomycin and Zosyn->cefepime->meropenem. During that admission, she was also found to have a PE and was started on therapeutic dose Lovenox. In the ED, she had one set of BCx sent from the [MASKED] and one peripheral. ED notes report erythema and a "small pustule" at the [MASKED] entry site. She received IVF and vancomycin 1000mg x1. She received Tylenol at her SNF prior to arrival In the ED, despite this she had a fever to 100.8F. Tachy to the 100-110s. Currently, she feels well with no complaints. Past Medical History: Osteoarthritis Hypothyroidism Hemochromatosis Asthma HCV- resolved Basal cell ca- forehead Non-Hodgkin's lymphoma located in liver. Social History: [MASKED] Family History: Her brother was diagnosed with kidney cancer at [MASKED] and died shortly thereafter. Her father died of a heart attack at [MASKED]. Her mother died of coronary artery disease at [MASKED]. Her sister died of COPD and she was a heavy smoker. She otherwise denies any other history of cancer, hypertension, stroke in her family. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: Tmax 100.8 T 99.2 BP 159 / 80 HR 96 RR 20 SpO2 93 RA General: NAD HEENT: Dry MM CV: RRR, no m/r/g PULM: Fine crackles at the left base, otherwise clear ABD: BS+, soft, NT/ND EXT: warm well perfused, no edema. SKIN: No rashes or skin breakdown. RUE [MASKED] site with erythema under taped areas, very slight erythema at the actual [MASKED] exit site. There is a small amount of pus able to be expressed from the exit site with crusting on the dressing. NEURO: alert and oriented x 4, [MASKED], EOMI, able to lift all extremities against resistance DISCHARGE PHYSICAL EXAM: VS: TC 97.6 103-125/52-70 [MASKED] 91-98%RA I/O: [MASKED] BM x1 GEN: comfortable, sitting in bed, NAD HEENT: Dry MM, OP clear CV: RRR, no m/r/g PULM: non-labored. CTA bilaterally. ABD: BS+, soft, NT/ND GU: Foley in place EXT: Trace BLE edema, no tremors. SKIN: Rash on posterior chest extending to buttocks/right leg region now resolved. Old [MASKED] site w/o discharge or tenderness NEURO: alert and oriented x 3. [MASKED], EOMI, able to lift all extremities against resistance ACCESS: PIV intact Pertinent Results: ADMISSION LABS: [MASKED] 01:16PM URINE COLOR-Straw APPEAR-Hazy* SP [MASKED] [MASKED] 01:16PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* [MASKED] 01:16PM URINE RBC-5* WBC-163* BACTERIA-MOD* YEAST-NONE EPI-0 [MASKED] 09:36PM [MASKED] PTT-33.0 [MASKED] [MASKED] 08:13PM LACTATE-0.9 [MASKED] 08:00PM GLUCOSE-114* UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-22 ANION GAP-17 [MASKED] 08:00PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.8 [MASKED] 08:00PM WBC-10.3* RBC-2.98* HGB-9.1* HCT-28.5* MCV-96 MCH-30.5 MCHC-31.9* RDW-18.4* RDWSD-64.5* [MASKED] 08:00PM PLT COUNT-426* [MASKED] 1:16 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 9:33 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: YEAST. >100,000 CFU/mL. [MASKED] 3:41 am CATHETER TIP-IV Source: RUE PICC. **FINAL REPORT [MASKED] WOUND CULTURE (Final [MASKED]: No significant growth. DISCHARGE LABS: [MASKED] 06:05AM BLOOD WBC-41.7* RBC-3.09* Hgb-9.4* Hct-29.7* MCV-96 MCH-30.4 MCHC-31.6* RDW-18.6* RDWSD-64.9* Plt [MASKED] [MASKED] 06:05AM BLOOD Neuts-96* Bands-0 Lymphs-1* Monos-0 Eos-3 Baso-0 [MASKED] Myelos-0 AbsNeut-40.03* AbsLymp-0.42* AbsMono-0.00* AbsEos-1.25* AbsBaso-0.00* [MASKED] 06:05AM BLOOD Glucose-89 UreaN-20 Creat-0.8 Na-139 K-4.9 Cl-101 HCO3-27 AnGap-11 [MASKED] 06:05AM BLOOD ALT-14 AST-16 LD(LDH)-183 AlkPhos-109* TotBili-0.4 [MASKED] 06:05AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.5 Mg-2. CUTE ISSUES = = = = = = ================================================================ #E coli UTI/Pyelonephritis: She was admitted with tachypnea, fever, and AMS concerning for sepsis. She was found to have Ecoli UTI and with treatment, her symptomology improved significantly. She was initiated on cefepime and vancomycin on admission. [MASKED] removed [MASKED] as concerned about potential source of infection but cultures are negative. Placed foley to get UA/UCx and measure post-void residuals. Post-void residuals remained high so kept Foley in. Initiated voiding trials without success. -Discontinued vancomycin as there was no evidence of gram positive infection ([MASKED]) -Initiated Cefepime (d1: [MASKED] then she was switched to DS Bactrim (d1: [MASKED] given rash and urine sensitivities result. She needs a 14D course of ABX total as concern of pyelonephritis on recent CT torso. Her course will complete on [MASKED]. She has an allergy to PCN; therefore, avoiding cephalosporins and ampicillin. Repeat urine culture [MASKED] did not show evidence of Ecoli but showed > 100,000 CFU/mL of yeast, likely a contaminant given foley use so did not treat. #Urinary retention: Pt was not requiring a foley prior to this admission. Foley has been present for almost entire admission; several voiding trials during the week prior to discharge were unsuccessful. She is being discharged with a Foley catheter to rehab. This will be a transitional issue for the rehab facility to work on, and if the pt. is unable to void. She has follow up appointment with outpatient urology on [MASKED] at 8:30AM. #Diffuse Large B- Cell Lymphoma: After discussion with primary oncologist, Dr. [MASKED] was to initiate cycle 4 of R-mini-CHOP given that her most recent restaging imaging is consistent with marked improvement of her disease. Extensive discussion with family on [MASKED] with SW and attending physician, [MASKED]. Patient and family agreed to initiate C4 of R-mini-CHOP. She is currently D+6 of regimen today. She continues on infectious prophylaxis with acyclovir. Atovaquone on hold given Bactrim use as above TO RESUME ONCE OFF BACTRIM. Once UTI course completes, will restart Atovaquone. Initiated GCSF support on [MASKED] and will need to monitor CBC. #Rash: Resolved. Unclear etiology but attributed to cefepime use which was started for Ecoli UTI on admission. She has been off cefepime since [MASKED] and the rash has since resolved, continue to monitor for recurrence outpatient. #Femoral fracture: Initially presented to an OSH w/ a left femoral fracture in the setting of a mechanical fall. Orthopedic surgery determined she could have surgery if desired but non-operative management is also appropriate. Pt. did not wish to have surgery. She continues with physical therapy in-house and is being transitioned to a rehab facility outpatient. #Psychosis: This occurred last hospitalization likely multifactorial in setting of poly-pharmacy, fever iso active infection. She responded well to zyprexa 5mg daily. This was held at discharge. #Malnutrition Risk: Concern for overall decrease in nutritional status. She makes attempt to eat but her intake remains poor. Nutrition consulted and thinks if within goals of care, may benefit from enteral feeding. Will continue to monitor outpatient. #Constipation: stooling daily, continues on bowel regimen #PE: On therapeutic Lovenox 60mg q12hrs #Hypothyroidism: continues levothyroxine. #COPD: Continue albuterol and Advair TRANSITIONAL ISSUES = = = = = = ================================================================ []Will need CBCs to monitor her blood counts. Please check them on [MASKED] and fax results to [MASKED], Dr. [MASKED] [MASKED] for monitoring. []Will need Oncology follow up w/ Dr. [MASKED] to discuss further treatment -- this is scheduled for [MASKED] []Please monitor platelets while the pt is on lovenox. She is on this for her pulmonary emboli. Should her plts drop to between [MASKED], please reduce the dose in half (from 60bid to 30bid). If plts drop below 30K, please stop lovenox. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Filgrastim-sndz 300 mcg SC Q24H 2. Atovaquone Suspension 1500 mg PO DAILY 3. Enoxaparin Sodium 60 mg SC Q12H 4. Acyclovir 400 mg PO TID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD Q24H 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Multivitamins 1 TAB PO DAILY 13. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Senna 8.6 mg PO BID:PRN constipation 3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days you will continue this medication until [MASKED] 4. Acyclovir 400 mg PO TID 5. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea 6. Enoxaparin Sodium 60 mg SC Q12H 7. Filgrastim-sndz 300 mcg SC Q24H 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD Q24H 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Montelukast 10 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. HELD- Atovaquone Suspension 1500 mg PO DAILY This medication was held. Do not restart Atovaquone Suspension until your outpatient team advises you to restart. likely restart [MASKED] after finishing course of Bactrim for UTI. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: =================== Ecoli Bacteruria Pyelonephritis Diffuse large B cell lymphoma Secondary: ================== Femoral fracture Chronic obstructive pulmonary disease Pulmonary emboli Steroid psychosis/delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [MASKED], You were admitted due to fever and found to have a urinary tract infection. You were placed on IV Antibiotics and your line was removed with improvement in your symptoms. You will continue oral antibiotics at the rehabilitation facility for a 2 week course. You also received your fourth cycle of chemotherapy (R-mini-CHOP). You tolerated this very well and will continue your daily neupogen injections until your outpatient team advises you to discontinue. You will be discharged today and follow up as stated below. It was a pleasure taking care of you. Followup Instructions: [MASKED]
[]
[ "J449", "E039", "Z87891", "Z66", "K5900" ]
[ "A419: Sepsis, unspecified organism", "I2699: Other pulmonary embolism without acute cor pulmonale", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "J449: Chronic obstructive pulmonary disease, unspecified", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "F05: Delirium due to known physiological condition", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "E83119: Hemochromatosis, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate", "S72002D: Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing", "M9702XD: Periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter", "W19XXXD: Unspecified fall, subsequent encounter", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "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", "K5900: Constipation, unspecified" ]
10,049,746
24,332,085
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pravachol / Darvon / Carrot Attending: ___. Chief Complaint: Broken femur, newly diagnosed DLBCL Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: ___ w/ PMH hemochromatosis, hypothyroidism, anemia presents from ___ with a femur fracture s/p fall. She had a previous hip fracture in ___ with replacement at that time. Patient says that 6 weeks ago she began feeling weak and tired, with intermittent nausea causing a 20 pound weight loss. She was admitted to ___ as a result of these issues and found to be severely anemic at the time and given 2 units of blood. CT showed multiple liver masses and lymphadenopathy which was recently discovered to be Non-Hodgkin Lymphoma. Regarding her fall, she does not recall the entire circumstances of the events leading up to the fall, but she notes that she felt a little bit lightheaded. Denies loss of consciousness. Denies head strike. Landed on her left side after striking the bathtub. She was found wedged between the bathtub in the toilet. She denied CP, SOB, or palpitations preceding the fall. Denies recent urinary symptoms, abdominal pain, N/V/D. Her Hb at ___ was 7. She was given 1 pRBC. Foley in place from OSH. She also has a new diagnosis of Non Hodgkin's lymphoma with liver lesions and no evidence of lymphoma elsewhere. Daughter, husband, and patient are aware of the diagnosis, she has not yet seen an oncologist. She was informed by her primary care physician. She was seen in the ED by trauma surgery and orthopedics. Trauma surgery recommended touchdown weightbearing on the left lower extremity in that she does not need operative repair. They stated that the hardware appears well-positioned given her periprosthetic femur fracture. In the ED, initial vitals: T: 99.6 HR: 104 BP: 138/80 RR: 18 Sp02: 2L 95% Nasal Cannula Labs notable for: - Leukocytosis to 11.7, H/H 8.7/25.5 (given 1 u for 7.0 ___ -Coags wnl - Lactate 1.3 - UA with mod leuks, neg nitrites - Chem 7 wnl (Cr 0.7) - BNP 655 - Trop 0.01 @ 0703 on ___. - Urine culture and blood cultures drawn. - Active blood bank specimen. Imaging notable for: ___ EKG: Sinus rhythm at 86, no ischemia or arrhythmia, nonspecific TWI in V1, similar to prior EKG from ___. QTc: 425. Possible ___. ___ CTA CHEST: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. ___ CT C-spine: Degenerative changes without fracture or acute malalignment. ___ CT Head W/O contrast: No acute intracranial process.Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. ___ Left Hip IMPRESSION: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Pt given: - 2 mg IV morphine for pain x 3 (approx. Q4-6H) - IVF w/ NS @ 100 ml/hr. - CTX 1g x 1 at 13:16 - Lovenox 70 mg @ 14:35 - Levothyroxine 50 mcg 15:10 - Fluticasone/Salmeterol @ 15:17 - Zofran 4 mg @ 16:15 Vitals prior to transfer: T: 98.1 HR: 86 BP:108/56 RR:22 Sp02:97% Nasal Cannula On the floor, she was seen with her husband ___ and ___ daughter ___. She has some discomfort in her left leg she points to her distal femur. She denies any chest pain or tightness, she does endorse some mild shortness of breath. She denies any abdominal pain, constipation, diarrhea, dark or bloody stools, dysuria. Of note, she does endorse that she had increased urinary frequency prior to the Foley placement. She is anxious about the new cancer diagnosis. Review of systems is otherwise negative. Past Medical History: Osteoarthritis Hypothyroidism Hemochromatosis Asthma HCV- resolved Basal cell ca- forehead Non-Hodgkin's lymphoma located in liver. Social History: ___ Family History: Her brother was diagnosed with kidney cancer at ___ and died shortly thereafter. Her father died of a heart attack at ___. Her mother died of coronary artery disease at ___. Her sister died of COPD and she was a heavy smoker. She otherwise denies any other history of cancer, hypertension, stroke in her family. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VITALS: T: 98.2 BP: 144/80 HR: 97 RR: 18 Sp02: 90% 4L General: Alert, oriented, no acute distress, nasal cannula in place. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. distal pulses intact. Lungs: On 4L (patient could not tolerate sitting up due to leg pain), good air exchange, no increased work of breathing, no wheezes, rales or rhonchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place. Ext: No peripheral edema, some minor bruises on lower extremities bilaterally, able to move toes on both sides, exam limited by pain on LLE, able to move RLE normally. Neuro: CNII-XII grossly intact, normal sensation. DISCHARGE PHYSICAL: =================================== VS: 0332 98.0 PO 131/62 86 19 95 Ra tmax 98.5 ACCESS: Dual Lumen Non-Heparin Dependent Right Brachial PICC (placed ___ PHYSICAL EXAM: General: Sitting up in bed. NAD. A&Ox3. Very pleasant. HEENT: Mucosa pink, moist, non-inflammed. No conjunctival pallor. CV: Tachycardic, Regular rhythm. No murmurs, rubs, gallops. Lungs: Lungs CTAB. No wheezes, rales, rhonchi. Abdomen: Soft, nontender, non distended. Ext: 1+ edema of bilateral lower extremities, L>R. Neuro: A&O x3. Conversant. Remainder of neuro exam is non-focal. Skin: Multiple ecchymoses. no rashes, lesions, or petechiae noted. B/l LEs with hyperpigmented patches and shiny taut patches. Pertinent Results: ADMISSION LABS: = ================================================================ ___ 09:28PM GLUCOSE-136* UREA N-17 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16 ___ 09:28PM ALT(SGPT)-20 AST(SGOT)-52* LD(LDH)-541* ALK PHOS-68 TOT BILI-3.6* ___ 09:28PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-2.0 URIC ACID-4.2 ___ 09:28PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG ___ 09:28PM HCV VL-NOT DETECT ___ 09:28PM WBC-13.5* RBC-3.08* HGB-9.5* HCT-28.7* MCV-93 MCH-30.8 MCHC-33.1 RDW-21.0* RDWSD-58.8* ___ 09:28PM PLT COUNT-357 ___ 09:28PM ___ PTT-30.2 ___ ___ 03:40PM WBC-11.1* RBC-2.76* HGB-8.7* HCT-25.5* MCV-92 MCH-31.5 MCHC-34.1 RDW-20.5* RDWSD-57.5* ___ 03:40PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-7 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-8.66* AbsLymp-1.67 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.00* ___ 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 03:40PM PLT SMR-NORMAL PLT COUNT-318 ___ 01:23PM LACTATE-1.3 ___ 08:04AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:04AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0 LEUK-MOD* ___ 08:04AM URINE RBC-42* WBC-35* BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:04AM URINE MUCOUS-RARE* ___ 07:03AM GLUCOSE-117* UREA N-19 CREAT-0.7 SODIUM-134 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15 ___ 07:03AM ALT(SGPT)-21 AST(SGOT)-66* LD(LDH)-656* ALK PHOS-67 TOT BILI-5.8* DIR BILI-1.0* INDIR BIL-4.8 ___ 07:03AM cTropnT-<0.01 proBNP-655* ___ 07:03AM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.1 URIC ACID-5.5 ___ 07:03AM HAPTOGLOB-36 ___ 07:03AM WBC-12.0* RBC-2.89* HGB-9.0* HCT-26.5* MCV-92# MCH-31.1 MCHC-34.0 RDW-19.3* RDWSD-56.6* ___ 07:03AM NEUTS-76* BANDS-1 LYMPHS-16* MONOS-5 EOS-0 BASOS-0 ___ MYELOS-2* AbsNeut-9.24* AbsLymp-1.92 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00* ___ 07:03AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+* ___ 07:03AM PLT SMR-NORMAL PLT COUNT-331 ___ 07:03AM ___ PTT-23.6* ___ DISCHARGE LABS: =============================================================== ___ 12:00AM BLOOD WBC-5.2# RBC-2.77*# Hgb-8.4*# Hct-25.8*# MCV-93 MCH-30.3 MCHC-32.6 RDW-17.8* RDWSD-57.4* Plt ___ ___ 12:00AM BLOOD Neuts-62 Bands-2 Lymphs-15* Monos-10 Eos-4 Baso-7* ___ Myelos-0 AbsNeut-1.60 AbsLymp-0.38* AbsMono-0.25 AbsEos-0.10 AbsBaso-0.18* ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD ___ ___ 12:00AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-138 K-3.9 Cl-99 HCO3-26 AnGap-13 ___ 12:00AM BLOOD ALT-9 AST-12 AlkPhos-115* TotBili-0.5 ___ 12:00AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1 IMAGING/STUDIES: =============================================================== ___: NCHCT:IMPRESSION: No acute intracranial process. Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. ___ CTA:IMPRESSION: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. ___: CT C-Spine: Degenerative changes without fracture or acute malalignment. ___: Hip XR: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. ___: ECHO:IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mildly dilated aortic arch Mild mitral regurgitation. Moderate pulmonary hypertension. ___: CT 1. No acute intracranial process. 2. Re-demonstration of complete opacification of the left frontal sinus and ethmoid air cells with apparent demineralization of the left ethmoid septa and extension into the left orbit, again concerning for underlying mass lesion. Nonurgent MRI is again recommended for further evaluation. 1. No infectious source identified in the abdomen and pelvis. 2. Upper abdominal lymphadenopathy, the largest conglomerate measuring up to 2.6 x 2.4 cm in the gastrohepatic ligament, compatible with provided history of lymphoma. 3. Multiple hypoenhancing hepatic masses, the largest measuring up to 5.5 x 4.4 cm, likely representing lymphomatous involvement. 4. Signs of excess fluid including small bilateral pleural effusions, trace pelvic free fluid, and mild body wall edema. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. ___: CT Chest: 1. Persistent small bilateral non hemorrhagic pleural effusions, similar to ___ chest radiograph given difference of technique, though increased since ___ chest CTA 2. Bibasilar pulmonary opacities most consistent with compressive atelectasis. Clinical correlation for superimposed infection is recommended. 3. Small airways disease with bronchial wall thickening. No mucus plugging. 4. 0.3 cm right upper lobe pulmonary nodule, unchanged since ___. 5. Innumerable hepatic masses, better characterized on CT abdomen/pelvis from ___, most consistent with lymphomatous involvement. ___ Video Swallow: IMPRESSION: Transient penetration with thin and nectar liquids. No aspiration. ___ FEMUR (AP & LAT) LEFT: IMPRESSION: Unchanged periprosthetic left femur fracture. Degenerative changes in the left knee. ___ LLE Ultrasound: IMPRESSION: -No evidence of deep venous thrombosis in the left lower extremity veins. -2 small fluid collections in the popliteal fossa are likely continuous with each other, likely representing a ruptured ___ cyst. ___ ECHO: Conclusions There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the left ventricular cavity appears smaller, c/w underfilling. Other findings are similar. ___ MRI brain with and without contrast: IMPRESSION: 1. The imaging findings are overall concerning for central pontine myelinolysis. Differential considerations subacute infarct or other demyelinating process is considered much less likely given the symmetric bilateral appearance of the abnormality with classic sparing of the peripheral pons and cortical spinal tracts. 2. Scattered foci of gradient echo susceptibility artifact, compatible with prior micro hemorrhages in a distribution suggestive of underlying amyloid angiopathy. 3. Prominent periventricular subcortical T2/FLAIR white matter hyperintensities the subcortical and periventricular white matter are nonspecific and nonenhancing, commonly seen in setting of chronic microangiopathy in a patient of this age. 4. No evidence of abnormal enhancement to suggest intracranial metastatic disease at this time. 5. Additional findings described above. ___ CTA CHEST: IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level or aortic abnormality. Assessment of subsegmental pulmonary arteries is limited due to respiratory motion artifact. 2. Interval resolution of pleural effusions. 3. Enlarged right and left main pulmonary arteries suggests pulmonary arterial hypertension. 4. Known hepatic masses are better assessed on prior CT abdomen and pelvis dated ___ due to timing of the contrast bolus. ___ FEMUR (AP & LAT) LEFT IMPRESSION: Compared to the prior study there has been no significant interval change. The left total hip arthroplasty is again visualized. A periprosthetic oblique fracture through the proximal feet femoral diaphysis is again noted. This is unchanged in alignment compared to the prior study. No callus formation is identified. No periprosthetic loosening is visualized. Degenerative changes are again visualized in the left knee. ___ MRI without contrast: IMPRESSION: 1. Previously identified periprosthetic fracture appears slightly more distracted than prior CT on ___ but likely similar to x-ray from ___. 2. There is a large fluid collection posterior to the left total-hip replacement primarily centered deep to the gluteus maximus muscle with apparent extension to the neck of the femoral component and insinuating between the fracture fragment and the prosthesis. 3. Ovoid lesion centered within the proximal vastus intermedius/vastus lateralis demonstrating internal STIR heterogeneity with central T1 hypointensity but peripheral T1 hyperintensity most likely represents a hematoma. Follow-up imaging should be performed to ensure resolution. 4. There is a small amount of fluid deep to the hamstring insertion at the Left ischial tuberosity which may represent sequela of partial tearing and/or calcific tendinitis as seen on prior CT RECOMMENDATION: ___ week follow-up MRI to ensure resolution of presumed hematoma in the proximal thigh. PATHOLOGY: ================ ___ CSF cytology report: No malignant cells. ___ CSF Flow cytometry INTERPRETATION: Non-diagnostic study. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells for analysis. Correlation with clinical, morphologic (see separate cytology report ___-___) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. MICRO: ========================================================== ___ 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 1710 ON ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ (___) @ ___, ___. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. ___ 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ Enterovirus Culture (Final ___: No Enterovirus isolated. ___ 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ___ 5:28 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 1710 ON ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ (___) @ ___, ___. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. Brief Hospital Course: Ms. ___ is a ___ woman with a history of COPD, hypothyroidism, and hemochromatosis who presented as a transfer from an outside hospitalwith a new left femoral fracture, as well as fatigue, nausea, anemia, and new liver lesions on outside hospital abdominal CT, now biopsy-proven diffuse large B-cell lymphoma. She also had new PEs (now on Lovenox). She started treatment for DLBCL with mini R-CHOP. Her course was complicated by persistently elevated bilirubin (likely due to liver disease and hemolysis), warm hemolytic anemia (on Rituxan), steroid psychosis/delirium, and hypoxia that ultimately required a stay in the FICU. Her mental status ultimately improved and she was weaned off oxygen. On the floor she continued to improve, worked with ___ and was deemed stable to continue chemo. She is now being discharged on C3D10 of R-mini-CHOP. ACUTE ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Diffuse Large B- Cell Lymphoma: During an outpatient workup for anemia, a CT scan that showed numerous liver lesions. Biopsies show high-grade diffuse large B-cell lymphoma with high nuclear proliferation index (>90%). She was initially started on treatment with only cyclophosphamide on ___ and Solu-Medrol on ___ and ___ due to an elevated bilirubin. The patient then developed severe delirium and hypoxia from volume overload and was transferred to the FICU on ___. While in the ICU the patient briefly required BIPAP support and improved with diuresis. Her delirium improved with the discontinuation of dilaudid and olanzapine 10 mg twice per day. Following discharge from the ICU she subsequently received dose-reduced vincristine and Adriamycin on ___ and Rituxan on ___. Over the course of the next week the patient was weaned to room air, her mental status returned to baseline, and she began to work with ___. Per the recommendations of her primary oncologist, it was decided to start her next cycle of chemo inpatient. On ___ she received R-CHOP w/ a dose-reduced prednisone regimen. She started a cycle of R-mini-chop on ___, which she tolerated well. She started G-CSF on ___ and is being continued on it upon discharge. # Pulmonary embolism # COPD # Hypoxia (resolved) On admission, CTA was notable for new segmental and subsegmental PEs. She was started on therapeutic Lovenox. The patient was stable on ___ NC/facemask and intermittently off of additional oxygen. After receiving 4L of IVF during prep for her chemo, she developed new onset increasing tachypnea, hypoxia and tachycardia to the 140s. Her hypoxia and tachycardia significantly improved in the ICU with diuresis. The patient progressively was able to be weaned off of O2 on the ___ service, and returned to her baseline respiratory status. She has been maintained on therapeutic Lovenox and will be discharged on Lovenox. # Femoral fracture: The patient initially presented to an OSH w/ a left femoral fracture in the setting of a mechanical fall. X-rays showed an acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Orthopedic surgery determined she could have surgery if desired but non-operative management is fine as well. The pt did not wish to have surgery. The patient received pain control initially with Tylenol, oxycodone, and morphine with good effect. She worked with physical therapy when she returned from the ICU and was reevaluated by ortho who recommended no interventions and ___ until discharge to an acute rehabilitation facility. She will continue getting ___ at her rehab facility. # Urinary retention: Pt was not requiring a foley prior to this admission. Foley has been present for almost entire admission; several voiding trials during the week prior to discharge were unsuccessful. Discontinued olanzapine, which was felt to be the only drug contributing to urinary retention. She is being discharged with a foley catheter to rehab. This will be a transitional issue for the rehab facility to work on, and if the pt is unable to void, she should follow up with outpatient urology. # Hemolytic anemia: The patient was noted to have an elevated indirect bilirubin. Labs showed a warm hemolytic anemia with Coombs (+), anti-C3 (+), and haptoglobin <10. Her LFTs and LDH remained stable. An eluate test was negative. Given that she was receiving Rituxan as part of her DLBCL regimen, there was no need for additional treatment. It was suspected that this was secondary to the patient's hematologic malignancy. # Psychosis (resolved: The patient became psychotic/delirious after receiving high dose steroids on ___, ultimately requiring ICU transfer due to a lack of response to Haldol and increased nursing requirements. She was started on standing Olanzapine and Dilaudid in the ICU, which ultimately led to better control of agitation and pain. However, she became non-responsive to questions and commands. On transfer back to the ___ service, her mental status progressively improved once Dilaudid was discontinued. Of note, the patient underwent an EEG that showed epileptiform discharges, but no organized seizure activity. When she underwent her second cycle of chemotherapy w/ R-CHOP her prednisone dose was modified to 4mg PO QD x3 days and she was started on Olanzapine 10mg PO QD for 3 days for prophylaxis of steroid induced delirium. This regimen worked and she underwent her second round of chemo without issue. She was then continued on Olanzapine 2.5mg thereafter. Olanzapine was eventually discontinued several days prior to discharge(due to concern for urinary retention), and the pt did not have any further sx of psychosis or AMS once off the olanzapine. # ?GPC bacteremia (determined to be contaminant). Labs in the ICU showed a lactic acidosis and new leukocytosis. She was started on Cefepime and Vancomycin. 1 culture bottle grew coag negative staph and corynebacterium, which was deemed to likely be a contaminant. She received a course of linezolid for growth of GPC in the setting of vancomycin. Ultimately, she was transitioned off of antibiotics on the ___ service without incident. CHRONIC ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Tachycardia Baseline is 100-120s, was diagnosed w/sinus tachycardia as outpatient and put on metoprolol XL 50mg PO. Also had new PEs on admission w/ assoc tachycardia. EKGs showed NSR. Cardiology was consulted and felt this is consistent with atrial tachycardia; they agreed on continuing metoprolol. Her dose was increased to 100mg daily. #Hypothyroidism: The patient was maintained on her home levothyroxine. TRANSITIONAL ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ []Will need follow up w/ Ortho w/Dr. ___ ___ -- this is scheduled for ___ []Will need CBCs to monitor her blood counts. Please check them on ___ and ___ and fax them to ___ to Dr. ___ for monitoring. []Will need Oncology follow up w/ Dr. ___ to discuss further treatment -- this is scheduled for ___ []Please monitor platelets while the pt is on lovenox. She is on this for her pulmonary emboli. Should her plts drop to between ___, please reduce the dose in half (from 60bid to 30bid). If plts drop below 30K, please stop lovenox. DNR/DNI Contact: ___ (daughter) ___, ___ (daughter, current location of husband, ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Montelukast 10 mg PO DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Acyclovir 400 mg PO TID 2. Atovaquone Suspension 1500 mg PO DAILY 3. Enoxaparin Sodium 60 mg SC Q12H 4. Filgrastim-sndz 300 mcg SC Q24H RX *filgrastim [Neupogen] 300 mcg/0.5 mL 1 syringe SC q24 Disp #*5 Syringe Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD Q24H 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 12. Levothyroxine Sodium 50 mcg PO DAILY 13. HELD- Montelukast 10 mg PO DAILY This medication was held. Do not restart ___ until your oncologist or PCP determines it is ok to take it again. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Femur fracture Diffuse large B cell lymphoma Pulmonary emboli Secondary: Steroid psychosis/delirium Hypoxemic respiratory failure Warm agglutinin hemolytic anemia Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why was I in the hospital? - You fell at home and were found to have a broken hip - We found out that you had blood clots in your lungs - You were recently diagnosed with lymphoma and needed to begin treatment What was done while I was in the hospital? - You were seen by the orthopedic surgeons who determined that you did not need surgery for your broken hip. - You were started on blood thinners for the blood clots in your lungs. - You received chemotherapy to treat your lymphoma. - During the chemotherapy, you became very confused; this was likely because of the steroids and pain medications you were being given. - You were moved to the ICU for several days because of your confusion and difficulty breathing - In the ICU you received medication to help you urinate, which helped to improve your breathing - Your confusion and breathing improved enough for you to be moved back to the general lymphoma floor. - While on the general floor, your cell counts came back up. - We gave you a second cycle of chemotherapy which you tolerated well. - You worked with physical therapy and became strong enough to go to an acute rehab facility. What should I do when leave the hospital? - You should work with physical therapy at the rehabilitation facility - You should have your blood counts checked about every three days at the rehabilitation facility - You should take all of your medications as prescribed, especially the medications preventing bacterial and viral infections - Please attend your follow-up appointment with your oncologist to discuss your future treatment plan - If you have fevers, chills, feel more confused, have problems breathing, chest pain, or generally feel unwell, please call your oncologist Sincerely, Your ___ Treatment Team Followup Instructions: ___
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Allergies: Pravachol / Darvon / Carrot Chief Complaint: Broken femur, newly diagnosed DLBCL Major Surgical or Invasive Procedure: [MASKED] line placement History of Present Illness: [MASKED] w/ PMH hemochromatosis, hypothyroidism, anemia presents from [MASKED] with a femur fracture s/p fall. She had a previous hip fracture in [MASKED] with replacement at that time. Patient says that 6 weeks ago she began feeling weak and tired, with intermittent nausea causing a 20 pound weight loss. She was admitted to [MASKED] as a result of these issues and found to be severely anemic at the time and given 2 units of blood. CT showed multiple liver masses and lymphadenopathy which was recently discovered to be Non-Hodgkin Lymphoma. Regarding her fall, she does not recall the entire circumstances of the events leading up to the fall, but she notes that she felt a little bit lightheaded. Denies loss of consciousness. Denies head strike. Landed on her left side after striking the bathtub. She was found wedged between the bathtub in the toilet. She denied CP, SOB, or palpitations preceding the fall. Denies recent urinary symptoms, abdominal pain, N/V/D. Her Hb at [MASKED] was 7. She was given 1 pRBC. Foley in place from OSH. She also has a new diagnosis of Non Hodgkin's lymphoma with liver lesions and no evidence of lymphoma elsewhere. Daughter, husband, and patient are aware of the diagnosis, she has not yet seen an oncologist. She was informed by her primary care physician. She was seen in the ED by trauma surgery and orthopedics. Trauma surgery recommended touchdown weightbearing on the left lower extremity in that she does not need operative repair. They stated that the hardware appears well-positioned given her periprosthetic femur fracture. In the ED, initial vitals: T: 99.6 HR: 104 BP: 138/80 RR: 18 Sp02: 2L 95% Nasal Cannula Labs notable for: - Leukocytosis to 11.7, H/H 8.7/25.5 (given 1 u for 7.0 [MASKED] -Coags wnl - Lactate 1.3 - UA with mod leuks, neg nitrites - Chem 7 wnl (Cr 0.7) - BNP 655 - Trop 0.01 @ 0703 on [MASKED]. - Urine culture and blood cultures drawn. - Active blood bank specimen. Imaging notable for: [MASKED] EKG: Sinus rhythm at 86, no ischemia or arrhythmia, nonspecific TWI in V1, similar to prior EKG from [MASKED]. QTc: 425. Possible [MASKED]. [MASKED] CTA CHEST: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. [MASKED] CT C-spine: Degenerative changes without fracture or acute malalignment. [MASKED] CT Head W/O contrast: No acute intracranial process.Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. [MASKED] Left Hip IMPRESSION: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Pt given: - 2 mg IV morphine for pain x 3 (approx. Q4-6H) - IVF w/ NS @ 100 ml/hr. - CTX 1g x 1 at 13:16 - Lovenox 70 mg @ 14:35 - Levothyroxine 50 mcg 15:10 - Fluticasone/Salmeterol @ 15:17 - Zofran 4 mg @ 16:15 Vitals prior to transfer: T: 98.1 HR: 86 BP:108/56 RR:22 Sp02:97% Nasal Cannula On the floor, she was seen with her husband [MASKED] and [MASKED] daughter [MASKED]. She has some discomfort in her left leg she points to her distal femur. She denies any chest pain or tightness, she does endorse some mild shortness of breath. She denies any abdominal pain, constipation, diarrhea, dark or bloody stools, dysuria. Of note, she does endorse that she had increased urinary frequency prior to the Foley placement. She is anxious about the new cancer diagnosis. Review of systems is otherwise negative. Past Medical History: Osteoarthritis Hypothyroidism Hemochromatosis Asthma HCV- resolved Basal cell ca- forehead Non-Hodgkin's lymphoma located in liver. Social History: [MASKED] Family History: Her brother was diagnosed with kidney cancer at [MASKED] and died shortly thereafter. Her father died of a heart attack at [MASKED]. Her mother died of coronary artery disease at [MASKED]. Her sister died of COPD and she was a heavy smoker. She otherwise denies any other history of cancer, hypertension, stroke in her family. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VITALS: T: 98.2 BP: 144/80 HR: 97 RR: 18 Sp02: 90% 4L General: Alert, oriented, no acute distress, nasal cannula in place. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. distal pulses intact. Lungs: On 4L (patient could not tolerate sitting up due to leg pain), good air exchange, no increased work of breathing, no wheezes, rales or rhonchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place. Ext: No peripheral edema, some minor bruises on lower extremities bilaterally, able to move toes on both sides, exam limited by pain on LLE, able to move RLE normally. Neuro: CNII-XII grossly intact, normal sensation. DISCHARGE PHYSICAL: =================================== VS: 0332 98.0 PO 131/62 86 19 95 Ra tmax 98.5 ACCESS: Dual Lumen Non-Heparin Dependent Right Brachial PICC (placed [MASKED] PHYSICAL EXAM: General: Sitting up in bed. NAD. A&Ox3. Very pleasant. HEENT: Mucosa pink, moist, non-inflammed. No conjunctival pallor. CV: Tachycardic, Regular rhythm. No murmurs, rubs, gallops. Lungs: Lungs CTAB. No wheezes, rales, rhonchi. Abdomen: Soft, nontender, non distended. Ext: 1+ edema of bilateral lower extremities, L>R. Neuro: A&O x3. Conversant. Remainder of neuro exam is non-focal. Skin: Multiple ecchymoses. no rashes, lesions, or petechiae noted. B/l LEs with hyperpigmented patches and shiny taut patches. Pertinent Results: ADMISSION LABS: = ================================================================ [MASKED] 09:28PM GLUCOSE-136* UREA N-17 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16 [MASKED] 09:28PM ALT(SGPT)-20 AST(SGOT)-52* LD(LDH)-541* ALK PHOS-68 TOT BILI-3.6* [MASKED] 09:28PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-2.0 URIC ACID-4.2 [MASKED] 09:28PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG [MASKED] 09:28PM HCV VL-NOT DETECT [MASKED] 09:28PM WBC-13.5* RBC-3.08* HGB-9.5* HCT-28.7* MCV-93 MCH-30.8 MCHC-33.1 RDW-21.0* RDWSD-58.8* [MASKED] 09:28PM PLT COUNT-357 [MASKED] 09:28PM [MASKED] PTT-30.2 [MASKED] [MASKED] 03:40PM WBC-11.1* RBC-2.76* HGB-8.7* HCT-25.5* MCV-92 MCH-31.5 MCHC-34.1 RDW-20.5* RDWSD-57.5* [MASKED] 03:40PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-7 EOS-0 BASOS-0 [MASKED] MYELOS-0 AbsNeut-8.66* AbsLymp-1.67 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.00* [MASKED] 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [MASKED] 03:40PM PLT SMR-NORMAL PLT COUNT-318 [MASKED] 01:23PM LACTATE-1.3 [MASKED] 08:04AM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 08:04AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0 LEUK-MOD* [MASKED] 08:04AM URINE RBC-42* WBC-35* BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 08:04AM URINE MUCOUS-RARE* [MASKED] 07:03AM GLUCOSE-117* UREA N-19 CREAT-0.7 SODIUM-134 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15 [MASKED] 07:03AM ALT(SGPT)-21 AST(SGOT)-66* LD(LDH)-656* ALK PHOS-67 TOT BILI-5.8* DIR BILI-1.0* INDIR BIL-4.8 [MASKED] 07:03AM cTropnT-<0.01 proBNP-655* [MASKED] 07:03AM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.1 URIC ACID-5.5 [MASKED] 07:03AM HAPTOGLOB-36 [MASKED] 07:03AM WBC-12.0* RBC-2.89* HGB-9.0* HCT-26.5* MCV-92# MCH-31.1 MCHC-34.0 RDW-19.3* RDWSD-56.6* [MASKED] 07:03AM NEUTS-76* BANDS-1 LYMPHS-16* MONOS-5 EOS-0 BASOS-0 [MASKED] MYELOS-2* AbsNeut-9.24* AbsLymp-1.92 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00* [MASKED] 07:03AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+* [MASKED] 07:03AM PLT SMR-NORMAL PLT COUNT-331 [MASKED] 07:03AM [MASKED] PTT-23.6* [MASKED] DISCHARGE LABS: =============================================================== [MASKED] 12:00AM BLOOD WBC-5.2# RBC-2.77*# Hgb-8.4*# Hct-25.8*# MCV-93 MCH-30.3 MCHC-32.6 RDW-17.8* RDWSD-57.4* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-62 Bands-2 Lymphs-15* Monos-10 Eos-4 Baso-7* [MASKED] Myelos-0 AbsNeut-1.60 AbsLymp-0.38* AbsMono-0.25 AbsEos-0.10 AbsBaso-0.18* [MASKED] 12:00AM BLOOD Plt [MASKED] [MASKED] 12:00AM BLOOD [MASKED] [MASKED] 12:00AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-138 K-3.9 Cl-99 HCO3-26 AnGap-13 [MASKED] 12:00AM BLOOD ALT-9 AST-12 AlkPhos-115* TotBili-0.5 [MASKED] 12:00AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1 IMAGING/STUDIES: =============================================================== [MASKED]: NCHCT:IMPRESSION: No acute intracranial process. Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. [MASKED] CTA:IMPRESSION: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. [MASKED]: CT C-Spine: Degenerative changes without fracture or acute malalignment. [MASKED]: Hip XR: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. [MASKED]: ECHO:IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mildly dilated aortic arch Mild mitral regurgitation. Moderate pulmonary hypertension. [MASKED]: CT 1. No acute intracranial process. 2. Re-demonstration of complete opacification of the left frontal sinus and ethmoid air cells with apparent demineralization of the left ethmoid septa and extension into the left orbit, again concerning for underlying mass lesion. Nonurgent MRI is again recommended for further evaluation. 1. No infectious source identified in the abdomen and pelvis. 2. Upper abdominal lymphadenopathy, the largest conglomerate measuring up to 2.6 x 2.4 cm in the gastrohepatic ligament, compatible with provided history of lymphoma. 3. Multiple hypoenhancing hepatic masses, the largest measuring up to 5.5 x 4.4 cm, likely representing lymphomatous involvement. 4. Signs of excess fluid including small bilateral pleural effusions, trace pelvic free fluid, and mild body wall edema. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. [MASKED]: CT Chest: 1. Persistent small bilateral non hemorrhagic pleural effusions, similar to [MASKED] chest radiograph given difference of technique, though increased since [MASKED] chest CTA 2. Bibasilar pulmonary opacities most consistent with compressive atelectasis. Clinical correlation for superimposed infection is recommended. 3. Small airways disease with bronchial wall thickening. No mucus plugging. 4. 0.3 cm right upper lobe pulmonary nodule, unchanged since [MASKED]. 5. Innumerable hepatic masses, better characterized on CT abdomen/pelvis from [MASKED], most consistent with lymphomatous involvement. [MASKED] Video Swallow: IMPRESSION: Transient penetration with thin and nectar liquids. No aspiration. [MASKED] FEMUR (AP & LAT) LEFT: IMPRESSION: Unchanged periprosthetic left femur fracture. Degenerative changes in the left knee. [MASKED] LLE Ultrasound: IMPRESSION: -No evidence of deep venous thrombosis in the left lower extremity veins. -2 small fluid collections in the popliteal fossa are likely continuous with each other, likely representing a ruptured [MASKED] cyst. [MASKED] ECHO: Conclusions There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [MASKED], the left ventricular cavity appears smaller, c/w underfilling. Other findings are similar. [MASKED] MRI brain with and without contrast: IMPRESSION: 1. The imaging findings are overall concerning for central pontine myelinolysis. Differential considerations subacute infarct or other demyelinating process is considered much less likely given the symmetric bilateral appearance of the abnormality with classic sparing of the peripheral pons and cortical spinal tracts. 2. Scattered foci of gradient echo susceptibility artifact, compatible with prior micro hemorrhages in a distribution suggestive of underlying amyloid angiopathy. 3. Prominent periventricular subcortical T2/FLAIR white matter hyperintensities the subcortical and periventricular white matter are nonspecific and nonenhancing, commonly seen in setting of chronic microangiopathy in a patient of this age. 4. No evidence of abnormal enhancement to suggest intracranial metastatic disease at this time. 5. Additional findings described above. [MASKED] CTA CHEST: IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level or aortic abnormality. Assessment of subsegmental pulmonary arteries is limited due to respiratory motion artifact. 2. Interval resolution of pleural effusions. 3. Enlarged right and left main pulmonary arteries suggests pulmonary arterial hypertension. 4. Known hepatic masses are better assessed on prior CT abdomen and pelvis dated [MASKED] due to timing of the contrast bolus. [MASKED] FEMUR (AP & LAT) LEFT IMPRESSION: Compared to the prior study there has been no significant interval change. The left total hip arthroplasty is again visualized. A periprosthetic oblique fracture through the proximal feet femoral diaphysis is again noted. This is unchanged in alignment compared to the prior study. No callus formation is identified. No periprosthetic loosening is visualized. Degenerative changes are again visualized in the left knee. [MASKED] MRI without contrast: IMPRESSION: 1. Previously identified periprosthetic fracture appears slightly more distracted than prior CT on [MASKED] but likely similar to x-ray from [MASKED]. 2. There is a large fluid collection posterior to the left total-hip replacement primarily centered deep to the gluteus maximus muscle with apparent extension to the neck of the femoral component and insinuating between the fracture fragment and the prosthesis. 3. Ovoid lesion centered within the proximal vastus intermedius/vastus lateralis demonstrating internal STIR heterogeneity with central T1 hypointensity but peripheral T1 hyperintensity most likely represents a hematoma. Follow-up imaging should be performed to ensure resolution. 4. There is a small amount of fluid deep to the hamstring insertion at the Left ischial tuberosity which may represent sequela of partial tearing and/or calcific tendinitis as seen on prior CT RECOMMENDATION: [MASKED] week follow-up MRI to ensure resolution of presumed hematoma in the proximal thigh. PATHOLOGY: ================ [MASKED] CSF cytology report: No malignant cells. [MASKED] CSF Flow cytometry INTERPRETATION: Non-diagnostic study. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells for analysis. Correlation with clinical, morphologic (see separate cytology report [MASKED]-[MASKED]) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. MICRO: ========================================================== [MASKED] 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED]. [MASKED] @ 1710 ON [MASKED]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] ([MASKED]) @ [MASKED], [MASKED]. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. [MASKED] 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT [MASKED] Enterovirus Culture (Final [MASKED]: No Enterovirus isolated. [MASKED] 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:28 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED]. [MASKED] @ 1710 ON [MASKED]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] ([MASKED]) @ [MASKED], [MASKED]. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a history of COPD, hypothyroidism, and hemochromatosis who presented as a transfer from an outside hospitalwith a new left femoral fracture, as well as fatigue, nausea, anemia, and new liver lesions on outside hospital abdominal CT, now biopsy-proven diffuse large B-cell lymphoma. She also had new PEs (now on Lovenox). She started treatment for DLBCL with mini R-CHOP. Her course was complicated by persistently elevated bilirubin (likely due to liver disease and hemolysis), warm hemolytic anemia (on Rituxan), steroid psychosis/delirium, and hypoxia that ultimately required a stay in the FICU. Her mental status ultimately improved and she was weaned off oxygen. On the floor she continued to improve, worked with [MASKED] and was deemed stable to continue chemo. She is now being discharged on C3D10 of R-mini-CHOP. ACUTE ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Diffuse Large B- Cell Lymphoma: During an outpatient workup for anemia, a CT scan that showed numerous liver lesions. Biopsies show high-grade diffuse large B-cell lymphoma with high nuclear proliferation index (>90%). She was initially started on treatment with only cyclophosphamide on [MASKED] and Solu-Medrol on [MASKED] and [MASKED] due to an elevated bilirubin. The patient then developed severe delirium and hypoxia from volume overload and was transferred to the FICU on [MASKED]. While in the ICU the patient briefly required BIPAP support and improved with diuresis. Her delirium improved with the discontinuation of dilaudid and olanzapine 10 mg twice per day. Following discharge from the ICU she subsequently received dose-reduced vincristine and Adriamycin on [MASKED] and Rituxan on [MASKED]. Over the course of the next week the patient was weaned to room air, her mental status returned to baseline, and she began to work with [MASKED]. Per the recommendations of her primary oncologist, it was decided to start her next cycle of chemo inpatient. On [MASKED] she received R-CHOP w/ a dose-reduced prednisone regimen. She started a cycle of R-mini-chop on [MASKED], which she tolerated well. She started G-CSF on [MASKED] and is being continued on it upon discharge. # Pulmonary embolism # COPD # Hypoxia (resolved) On admission, CTA was notable for new segmental and subsegmental PEs. She was started on therapeutic Lovenox. The patient was stable on [MASKED] NC/facemask and intermittently off of additional oxygen. After receiving 4L of IVF during prep for her chemo, she developed new onset increasing tachypnea, hypoxia and tachycardia to the 140s. Her hypoxia and tachycardia significantly improved in the ICU with diuresis. The patient progressively was able to be weaned off of O2 on the [MASKED] service, and returned to her baseline respiratory status. She has been maintained on therapeutic Lovenox and will be discharged on Lovenox. # Femoral fracture: The patient initially presented to an OSH w/ a left femoral fracture in the setting of a mechanical fall. X-rays showed an acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Orthopedic surgery determined she could have surgery if desired but non-operative management is fine as well. The pt did not wish to have surgery. The patient received pain control initially with Tylenol, oxycodone, and morphine with good effect. She worked with physical therapy when she returned from the ICU and was reevaluated by ortho who recommended no interventions and [MASKED] until discharge to an acute rehabilitation facility. She will continue getting [MASKED] at her rehab facility. # Urinary retention: Pt was not requiring a foley prior to this admission. Foley has been present for almost entire admission; several voiding trials during the week prior to discharge were unsuccessful. Discontinued olanzapine, which was felt to be the only drug contributing to urinary retention. She is being discharged with a foley catheter to rehab. This will be a transitional issue for the rehab facility to work on, and if the pt is unable to void, she should follow up with outpatient urology. # Hemolytic anemia: The patient was noted to have an elevated indirect bilirubin. Labs showed a warm hemolytic anemia with Coombs (+), anti-C3 (+), and haptoglobin <10. Her LFTs and LDH remained stable. An eluate test was negative. Given that she was receiving Rituxan as part of her DLBCL regimen, there was no need for additional treatment. It was suspected that this was secondary to the patient's hematologic malignancy. # Psychosis (resolved: The patient became psychotic/delirious after receiving high dose steroids on [MASKED], ultimately requiring ICU transfer due to a lack of response to Haldol and increased nursing requirements. She was started on standing Olanzapine and Dilaudid in the ICU, which ultimately led to better control of agitation and pain. However, she became non-responsive to questions and commands. On transfer back to the [MASKED] service, her mental status progressively improved once Dilaudid was discontinued. Of note, the patient underwent an EEG that showed epileptiform discharges, but no organized seizure activity. When she underwent her second cycle of chemotherapy w/ R-CHOP her prednisone dose was modified to 4mg PO QD x3 days and she was started on Olanzapine 10mg PO QD for 3 days for prophylaxis of steroid induced delirium. This regimen worked and she underwent her second round of chemo without issue. She was then continued on Olanzapine 2.5mg thereafter. Olanzapine was eventually discontinued several days prior to discharge(due to concern for urinary retention), and the pt did not have any further sx of psychosis or AMS once off the olanzapine. # ?GPC bacteremia (determined to be contaminant). Labs in the ICU showed a lactic acidosis and new leukocytosis. She was started on Cefepime and Vancomycin. 1 culture bottle grew coag negative staph and corynebacterium, which was deemed to likely be a contaminant. She received a course of linezolid for growth of GPC in the setting of vancomycin. Ultimately, she was transitioned off of antibiotics on the [MASKED] service without incident. CHRONIC ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Tachycardia Baseline is 100-120s, was diagnosed w/sinus tachycardia as outpatient and put on metoprolol XL 50mg PO. Also had new PEs on admission w/ assoc tachycardia. EKGs showed NSR. Cardiology was consulted and felt this is consistent with atrial tachycardia; they agreed on continuing metoprolol. Her dose was increased to 100mg daily. #Hypothyroidism: The patient was maintained on her home levothyroxine. TRANSITIONAL ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ []Will need follow up w/ Ortho w/Dr. [MASKED] [MASKED] -- this is scheduled for [MASKED] []Will need CBCs to monitor her blood counts. Please check them on [MASKED] and [MASKED] and fax them to [MASKED] to Dr. [MASKED] for monitoring. []Will need Oncology follow up w/ Dr. [MASKED] to discuss further treatment -- this is scheduled for [MASKED] []Please monitor platelets while the pt is on lovenox. She is on this for her pulmonary emboli. Should her plts drop to between [MASKED], please reduce the dose in half (from 60bid to 30bid). If plts drop below 30K, please stop lovenox. DNR/DNI Contact: [MASKED] (daughter) [MASKED], [MASKED] (daughter, current location of husband, [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Montelukast 10 mg PO DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. DiphenhydrAMINE [MASKED] mg PO QHS:PRN insomnia 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Acyclovir 400 mg PO TID 2. Atovaquone Suspension 1500 mg PO DAILY 3. Enoxaparin Sodium 60 mg SC Q12H 4. Filgrastim-sndz 300 mcg SC Q24H RX *filgrastim [Neupogen] 300 mcg/0.5 mL 1 syringe SC q24 Disp #*5 Syringe Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD Q24H 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 12. Levothyroxine Sodium 50 mcg PO DAILY 13. HELD- Montelukast 10 mg PO DAILY This medication was held. Do not restart [MASKED] until your oncologist or PCP determines it is ok to take it again. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Femur fracture Diffuse large B cell lymphoma Pulmonary emboli Secondary: Steroid psychosis/delirium Hypoxemic respiratory failure Warm agglutinin hemolytic anemia Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. Why was I in the hospital? - You fell at home and were found to have a broken hip - We found out that you had blood clots in your lungs - You were recently diagnosed with lymphoma and needed to begin treatment What was done while I was in the hospital? - You were seen by the orthopedic surgeons who determined that you did not need surgery for your broken hip. - You were started on blood thinners for the blood clots in your lungs. - You received chemotherapy to treat your lymphoma. - During the chemotherapy, you became very confused; this was likely because of the steroids and pain medications you were being given. - You were moved to the ICU for several days because of your confusion and difficulty breathing - In the ICU you received medication to help you urinate, which helped to improve your breathing - Your confusion and breathing improved enough for you to be moved back to the general lymphoma floor. - While on the general floor, your cell counts came back up. - We gave you a second cycle of chemotherapy which you tolerated well. - You worked with physical therapy and became strong enough to go to an acute rehab facility. What should I do when leave the hospital? - You should work with physical therapy at the rehabilitation facility - You should have your blood counts checked about every three days at the rehabilitation facility - You should take all of your medications as prescribed, especially the medications preventing bacterial and viral infections - Please attend your follow-up appointment with your oncologist to discuss your future treatment plan - If you have fevers, chills, feel more confused, have problems breathing, chest pain, or generally feel unwell, please call your oncologist Sincerely, Your [MASKED] Treatment Team Followup Instructions: [MASKED]
[]
[ "E872", "Z66", "E039", "J45909", "Z87891", "Y92230" ]
[ "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "I2699: Other pulmonary embolism without acute cor pulmonale", "E43: Unspecified severe protein-calorie malnutrition", "J189: Pneumonia, unspecified organism", "S72302A: Unspecified fracture of shaft of left femur, initial encounter for closed fracture", "E872: Acidosis", "E870: Hyperosmolality and hypernatremia", "D709: Neutropenia, unspecified", "F05: Delirium due to known physiological condition", "D591: Other autoimmune hemolytic anemias", "M9702XA: Periprosthetic fracture around internal prosthetic left hip joint, initial encounter", "Z781: Physical restraint status", "Z66: Do not resuscitate", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "E83119: Hemochromatosis, unspecified", "E039: Hypothyroidism, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R0902: Hypoxemia", "E8770: Fluid overload, unspecified", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "R000: Tachycardia, unspecified", "D72829: Elevated white blood cell count, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E806: Other disorders of bilirubin metabolism", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R5081: Fever presenting with conditions classified elsewhere" ]
10,049,851
29,728,893
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: Bone marrow biopsy ___ History of Present Illness: ___ year old male with history of hypertension, gout. presenting as transfer from ___ with thrombocytopenia and epistaxis that has now resolved. Patient is ___ speaking only. Per son and daughter in-law, the patient developed a spontaneous nosebleed today. He was brought to ___ where he was found to have pancytopenia with significant thrombocytopenia, with platelets of 1K. He was then transferred to ___ for further management. In the ED, initial vitals were 96.6 70 146/74 16 100% RA. Labs showed WBC 1.3K, platelets <5K. Hemoglobin was 14.8. CXR showed posterior opacity that could represent PNA. A Rhino rocket was placed in the left nare with mild oozing of blood. Several ecchymotic lesions were noted over the upper extremities and roof of mouth. Hematology was consulted and recommended transfusion of one unit of platelets. Of note, the patient was recently in ___ where a few tooth extractions were done, with no significant bleeding being noted at that time (done around ___. He also reports he has been having increased bruising for past month. Of note, he was recently prescribed Probenecid for gout which he has been taking for ~ the past 5 days. It was prescribed ___ per his ___ pharmacy. On the floor, he has no complaints. Asking to eat. Family at bedside and available to translate during interview. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: Hypertension Gout Social History: ___ Family History: No family history of blood disorders. Physical Exam: ADMISSION EXAM: Vitals: VSS GEN: Alert, oriented to name, place and situation. NAD HEENT: NCAT, PERRL, sclerae anicteric, hematomas on tongue Neck: Supple, no JVD/LAD CV: S1S2, RRR, no murmurs, rubs or gallops. RESP: crackles at bilateral bases, good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. no HSM EXTR: No lower leg edema, no clubbing or cyanosis. Mild edema of right great toe, no erythema or tenderness. Good ROM Neuro: Cranial nerves ___ grossly intact, muscle strength ___ in all major muscle groups, sensation to light touch intact, non-focal. Skin: Scattered ecchymoses on b/l UE PSYCH: Appropriate and calm. DISCHARGE EXAM: Pertinent Results: ADMISSION LABS: ___ 02:15AM BLOOD WBC-1.3* RBC-5.05 Hgb-14.8 Hct-43.0 MCV-85 MCH-29.3 MCHC-34.4 RDW-13.1 RDWSD-40.5 Plt Ct-<5 ___ 02:15AM BLOOD Neuts-6* Bands-0 ___ Monos-39* Eos-6 Baso-0 ___ Metas-3* Myelos-3* Plasma-1* Other-6* AbsNeut-0.08* AbsLymp-0.47* AbsMono-0.51 AbsEos-0.08 AbsBaso-0.00* ___ 02:15AM BLOOD ___ PTT-32.2 ___ ___ 02:15AM BLOOD Glucose-102* UreaN-24* Creat-1.0 Na-133 K-4.0 Cl-97 HCO3-26 AnGap-14 ___ 03:30AM BLOOD LD(LDH)-316* ___ 09:20AM BLOOD TotProt-7.3 UricAcd-6.3 ___ 03:30AM BLOOD Iron-52 ___ 03:30AM BLOOD calTIBC-241* Ferritn-345 TRF-185* ___ 09:20AM BLOOD VitB12-643 Folate-14.8 ___ 09:20AM BLOOD HIV Ab-Negative LABS: WBC 10.4, Hb 11.1, Hct 32.6. plt 28. MCV 85, ANC 7.2 BNP: Na 140, K 3.6, Cl 105, HCO3 27, BUN 18, Cr 0.9. ALT 35, AST 24, ALP 65, Tbil 0.3 Ca 9.3, Mg 1.8, Ph 2.6 IRON: TIBC 241 (low) Transferrin ___ Ferritin 185 Micro: - HBsAg negative. HBsAb positive. HBcAb negative. - HCV Ab negative - HIV Ab negative - EBV IgG (VCA, EBNA) positive. IgM (VCA) negative. - CMV IgG positive, IgM negative. STUDIES: CXR ___: IMPRESSION: Increased airspace opacity over the spine could represent pneumonia in the appropriate clinical context. Abdominal u/s ___: IMPRESSION: Normal sonographic appearance of the spleen. No splenomegaly. A . Brief Hospital Course: ASSESSMENT AND PLAN: ___ hx HTN, gout admitted with leukopenia/thrombocytopenia likely induced by probenicid. Now improving after 2 days of prednisone, 3 days off the probenicid. No longer leukopenic or neutropenic. # Thrombocytopenia: ___ bone marrow suggestive of toxic insult and suspect drug-related, possibly related to probenecid use, final read of BMBx pending. Viral studies all negative. Thought to be possibly drug induced ITP with autoimmune component leading to platelet destruction with additional bone marrow suppressive component. As WBC and ANC have normalized, this is suggestive of BM recovery. Received 3 platelet transfusions, platelets were 11 on day of discharge after 36 hours since last transfusion. As his platelets continued to drop with transfusions, this underscored concern for ITP. Given concern for ITP he was started on prednisone 60 mg QD on ___ and should take this for at least 2 weeks until he sees heme in clinic with dr. ___. - pt instructed to have a repeat CBC in ___ days through PCP, fax to Dr. ___ at ___. This was discussed with his PCP's office. On day of discharge, pt also received 1g/kg IVIG. Transfusion went smoothly without complications. The final core biopsy indicated granulocyte neoplasia with left shift, grade I fibrosis, and normal appearing megacaryocytes. There were not blasts. Flow cytometry pending at the time of discharge. During the hospital stay, his WBC recovered rapidly without growth factor support. # Epistaxis: likely ___ thrombocytopenia, had packing for 5 days. No drop in hct, bleeding stopped after 2 days. saline spray ___ sprays per nostril TID, should go home with this. Will also arrange f/u appointment with Dr. ___ in ___ weeks after discharge. # Hypertension: hold HCTZ given hx of gout, continue lisinopril. BPs well controlled inpatient. # Gout: currently no e/o acute flare. Hold probenecid, has been on allopurinol since ___. Should not ever take probenicid again. - f/u w/ PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Fluoxetine 20 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Probenecid ___ mg PO BID Discharge Medications: 1. Fluoxetine 20 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 6. Amoxicillin 500 mg PO Q8H starting on ___, take for 2 days RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day Disp #*6 Tablet Refills:*0 7. Outpatient Lab Work Please have your complete blood count drawn on ___. Dr. ___ has agreed to have this done. ___ should call his office on ___ to confirm. Discharge Disposition: Home Discharge Diagnosis: Epistaxis Leukopenia Thrombocytopenia, likely immune mediated thrombocytopenia Allergy to probenicid Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___ were admitted to ___ with a nose bleed and found to have very low platelets and white blood cells. These are the cells the help ___ form blood clots and fight infection. We think this occurred in response to the medication ___ were taking for gout, probenecid, which may have caused your body to form antibodies to your own platelets. ___ were seen by the Hematologists and a bone marrow biopsy performed which showed toxic insult such as related to a drug. ___ were treated with platelets to keep ___ from bleeding spontaneously and ___ were started on prednisone to suppress your body from attacking its platelets. Your platelets started to improve, and then on your last hospital day ___ were also given immunoglobulins to help boost the immune system. ___ SHOULD TELL ALL DOCTORS THAT ___ ARE ALLERGIC TO PROBENECID AND THAT IT MAKES YOUR WHITE BLOOD CELLS AND PLATELETS LOW. ___ were treated for a pneumonia with IV antibiotics for 5 days and will take two more days of antibiotics at home. Your breathing remained stable and ___ didn't have any fevers. Your nose stopped bleeding with the packing and that was removed on ___. ___ were given some afrin to help suppress bleeding and ___ were also given saline nasal spray to use to keep the nostrils moist. ___ can use that 4 times a day, spraying ___ times in each nostril. ___ will follow up with the ears, nose and throat doctor (___). ___ were given a new drug for prevention of gout flares called allopurinol. ___ should take 300 mg daily. Dr. ___ give ___ further prescriptions for flares of gout. Followup Instructions: ___
[ "D696", "D61818", "R040", "D72819", "M109", "I10", "T504X5A", "Y92009" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: Bone marrow biopsy [MASKED] History of Present Illness: [MASKED] year old male with history of hypertension, gout. presenting as transfer from [MASKED] with thrombocytopenia and epistaxis that has now resolved. Patient is [MASKED] speaking only. Per son and daughter in-law, the patient developed a spontaneous nosebleed today. He was brought to [MASKED] where he was found to have pancytopenia with significant thrombocytopenia, with platelets of 1K. He was then transferred to [MASKED] for further management. In the ED, initial vitals were 96.6 70 146/74 16 100% RA. Labs showed WBC 1.3K, platelets <5K. Hemoglobin was 14.8. CXR showed posterior opacity that could represent PNA. A Rhino rocket was placed in the left nare with mild oozing of blood. Several ecchymotic lesions were noted over the upper extremities and roof of mouth. Hematology was consulted and recommended transfusion of one unit of platelets. Of note, the patient was recently in [MASKED] where a few tooth extractions were done, with no significant bleeding being noted at that time (done around [MASKED]. He also reports he has been having increased bruising for past month. Of note, he was recently prescribed Probenecid for gout which he has been taking for ~ the past 5 days. It was prescribed [MASKED] per his [MASKED] pharmacy. On the floor, he has no complaints. Asking to eat. Family at bedside and available to translate during interview. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: Hypertension Gout Social History: [MASKED] Family History: No family history of blood disorders. Physical Exam: ADMISSION EXAM: Vitals: VSS GEN: Alert, oriented to name, place and situation. NAD HEENT: NCAT, PERRL, sclerae anicteric, hematomas on tongue Neck: Supple, no JVD/LAD CV: S1S2, RRR, no murmurs, rubs or gallops. RESP: crackles at bilateral bases, good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. no HSM EXTR: No lower leg edema, no clubbing or cyanosis. Mild edema of right great toe, no erythema or tenderness. Good ROM Neuro: Cranial nerves [MASKED] grossly intact, muscle strength [MASKED] in all major muscle groups, sensation to light touch intact, non-focal. Skin: Scattered ecchymoses on b/l UE PSYCH: Appropriate and calm. DISCHARGE EXAM: Pertinent Results: ADMISSION LABS: [MASKED] 02:15AM BLOOD WBC-1.3* RBC-5.05 Hgb-14.8 Hct-43.0 MCV-85 MCH-29.3 MCHC-34.4 RDW-13.1 RDWSD-40.5 Plt Ct-<5 [MASKED] 02:15AM BLOOD Neuts-6* Bands-0 [MASKED] Monos-39* Eos-6 Baso-0 [MASKED] Metas-3* Myelos-3* Plasma-1* Other-6* AbsNeut-0.08* AbsLymp-0.47* AbsMono-0.51 AbsEos-0.08 AbsBaso-0.00* [MASKED] 02:15AM BLOOD [MASKED] PTT-32.2 [MASKED] [MASKED] 02:15AM BLOOD Glucose-102* UreaN-24* Creat-1.0 Na-133 K-4.0 Cl-97 HCO3-26 AnGap-14 [MASKED] 03:30AM BLOOD LD(LDH)-316* [MASKED] 09:20AM BLOOD TotProt-7.3 UricAcd-6.3 [MASKED] 03:30AM BLOOD Iron-52 [MASKED] 03:30AM BLOOD calTIBC-241* Ferritn-345 TRF-185* [MASKED] 09:20AM BLOOD VitB12-643 Folate-14.8 [MASKED] 09:20AM BLOOD HIV Ab-Negative LABS: WBC 10.4, Hb 11.1, Hct 32.6. plt 28. MCV 85, ANC 7.2 BNP: Na 140, K 3.6, Cl 105, HCO3 27, BUN 18, Cr 0.9. ALT 35, AST 24, ALP 65, Tbil 0.3 Ca 9.3, Mg 1.8, Ph 2.6 IRON: TIBC 241 (low) Transferrin [MASKED] Ferritin 185 Micro: - HBsAg negative. HBsAb positive. HBcAb negative. - HCV Ab negative - HIV Ab negative - EBV IgG (VCA, EBNA) positive. IgM (VCA) negative. - CMV IgG positive, IgM negative. STUDIES: CXR [MASKED]: IMPRESSION: Increased airspace opacity over the spine could represent pneumonia in the appropriate clinical context. Abdominal u/s [MASKED]: IMPRESSION: Normal sonographic appearance of the spleen. No splenomegaly. A . Brief Hospital Course: ASSESSMENT AND PLAN: [MASKED] hx HTN, gout admitted with leukopenia/thrombocytopenia likely induced by probenicid. Now improving after 2 days of prednisone, 3 days off the probenicid. No longer leukopenic or neutropenic. # Thrombocytopenia: [MASKED] bone marrow suggestive of toxic insult and suspect drug-related, possibly related to probenecid use, final read of BMBx pending. Viral studies all negative. Thought to be possibly drug induced ITP with autoimmune component leading to platelet destruction with additional bone marrow suppressive component. As WBC and ANC have normalized, this is suggestive of BM recovery. Received 3 platelet transfusions, platelets were 11 on day of discharge after 36 hours since last transfusion. As his platelets continued to drop with transfusions, this underscored concern for ITP. Given concern for ITP he was started on prednisone 60 mg QD on [MASKED] and should take this for at least 2 weeks until he sees heme in clinic with dr. [MASKED]. - pt instructed to have a repeat CBC in [MASKED] days through PCP, fax to Dr. [MASKED] at [MASKED]. This was discussed with his PCP's office. On day of discharge, pt also received 1g/kg IVIG. Transfusion went smoothly without complications. The final core biopsy indicated granulocyte neoplasia with left shift, grade I fibrosis, and normal appearing megacaryocytes. There were not blasts. Flow cytometry pending at the time of discharge. During the hospital stay, his WBC recovered rapidly without growth factor support. # Epistaxis: likely [MASKED] thrombocytopenia, had packing for 5 days. No drop in hct, bleeding stopped after 2 days. saline spray [MASKED] sprays per nostril TID, should go home with this. Will also arrange f/u appointment with Dr. [MASKED] in [MASKED] weeks after discharge. # Hypertension: hold HCTZ given hx of gout, continue lisinopril. BPs well controlled inpatient. # Gout: currently no e/o acute flare. Hold probenecid, has been on allopurinol since [MASKED]. Should not ever take probenicid again. - f/u w/ PCP [MASKED] on [MASKED]: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Fluoxetine 20 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Probenecid [MASKED] mg PO BID Discharge Medications: 1. Fluoxetine 20 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Allopurinol [MASKED] mg PO DAILY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 6. Amoxicillin 500 mg PO Q8H starting on [MASKED], take for 2 days RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day Disp #*6 Tablet Refills:*0 7. Outpatient Lab Work Please have your complete blood count drawn on [MASKED]. Dr. [MASKED] has agreed to have this done. [MASKED] should call his office on [MASKED] to confirm. Discharge Disposition: Home Discharge Diagnosis: Epistaxis Leukopenia Thrombocytopenia, likely immune mediated thrombocytopenia Allergy to probenicid Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [MASKED] were admitted to [MASKED] with a nose bleed and found to have very low platelets and white blood cells. These are the cells the help [MASKED] form blood clots and fight infection. We think this occurred in response to the medication [MASKED] were taking for gout, probenecid, which may have caused your body to form antibodies to your own platelets. [MASKED] were seen by the Hematologists and a bone marrow biopsy performed which showed toxic insult such as related to a drug. [MASKED] were treated with platelets to keep [MASKED] from bleeding spontaneously and [MASKED] were started on prednisone to suppress your body from attacking its platelets. Your platelets started to improve, and then on your last hospital day [MASKED] were also given immunoglobulins to help boost the immune system. [MASKED] SHOULD TELL ALL DOCTORS THAT [MASKED] ARE ALLERGIC TO PROBENECID AND THAT IT MAKES YOUR WHITE BLOOD CELLS AND PLATELETS LOW. [MASKED] were treated for a pneumonia with IV antibiotics for 5 days and will take two more days of antibiotics at home. Your breathing remained stable and [MASKED] didn't have any fevers. Your nose stopped bleeding with the packing and that was removed on [MASKED]. [MASKED] were given some afrin to help suppress bleeding and [MASKED] were also given saline nasal spray to use to keep the nostrils moist. [MASKED] can use that 4 times a day, spraying [MASKED] times in each nostril. [MASKED] will follow up with the ears, nose and throat doctor ([MASKED]). [MASKED] were given a new drug for prevention of gout flares called allopurinol. [MASKED] should take 300 mg daily. Dr. [MASKED] give [MASKED] further prescriptions for flares of gout. Followup Instructions: [MASKED]
[]
[ "D696", "M109", "I10" ]
[ "D696: Thrombocytopenia, unspecified", "D61818: Other pancytopenia", "R040: Epistaxis", "D72819: Decreased white blood cell count, unspecified", "M109: Gout, unspecified", "I10: Essential (primary) hypertension", "T504X5A: Adverse effect of drugs affecting uric acid metabolism, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,049,902
21,559,583
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission labs: =============== ___ 10:00PM BLOOD WBC-14.2* RBC-3.62* Hgb-11.2 Hct-34.2 MCV-95 MCH-30.9 MCHC-32.7 RDW-14.1 RDWSD-48.5* Plt ___ ___ 10:00PM BLOOD Neuts-91.7* Lymphs-5.4* Monos-1.7* Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.05* AbsLymp-0.77* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.02 ___ 10:00PM BLOOD Glucose-162* UreaN-6 Creat-0.7 Na-138 K-3.7 Cl-100 HCO3-22 AnGap-16 . . Notable labs: ============= ___ 07:40AM BLOOD calTIBC-177* VitB12-162* Folate-<2 Hapto-374* Ferritn-317* TRF-136* ___ 07:40AM BLOOD Homocys-16.6* ___ 07:40AM BLOOD TSH-2.1 ___ 07:40AM BLOOD METHYLMALONIC ACID-PENDING . . Micro: ======== -___ MRSA screen (nasal swab): pending -___ Urine strep pneumo antigen: pending -___ Urine legionella antigen: negative for serogroup 1 -___ Flu A&B PCR: negative -___ Respiratroy viral panel: pending -___ UCx: mixed bacterial flora (final) Imaging: ========= - CXR (___): IMPRESSION: Findings concerning for multifocal pneumonia in the right lung. - ___ CT chest w/ contrast: "IMPRESSION: 1. Diffuse ground-glass opacification throughout bilateral lungs in a peribronchovascular distribution. Differential considerations include atypical/viral infection, sarcoidosis, hypersensitivity pneumonitis, drug toxicity, or respiratory bronchiolitis interstitial lung disease given the history smoking. 2. Bilateral pulmonary nodules measuring up to 6 mm are stable dating back to ___. 3. Mild confluent bilateral hilar lymphadenopathy." . . Discharge labs: ================ ___ 06:30AM BLOOD WBC-17.1* RBC-3.25* Hgb-10.1* Hct-31.6* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.2 RDWSD-50.3* Plt ___ ___ 06:30AM BLOOD Glucose-93 UreaN-7 Creat-0.7 Na-141 K-4.0 Cl-101 HCO3-26 AnGap-14 ___ 06:30AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.9 Mg-2.0 . . Brief Hospital Course: ___ smoker with history of cardiomyopathy, hypertension, asthma/COPD, prior desquamative interstitial pneumonia who presents with several weeks of cough and shortness of breath, found to have hypoxia. . . # Acute hypoxic respiratory failure # COPD exacerbation # Vaping-related lung disease -Hypoxia improved from 4L --> RA w/ prednisone 40 + standing duonebs + empiric abx -CT chest (___) showing GGOs throughout b/l upper & middle lobes consistent with ILD and no evidence of consolidation to suggest PNA -Pulmonology was consulted, they felt that her presentation was most likely due to recent vaping. -Stopped Zosyn ___ ___ given no convincing evidence for bacterial pneumonia -No new fevers or worsening respiratory symptoms off abx -Ambulatory VS on day of discharge were RR 24 and pOx 91-94% on room air -Discharged on duoneb taper, prednisone taper (decrease by 10 mg every 5 days, per Pulm recs), with plans to follow-up with Dr. ___ primary ___ -FYI: we submitted confidential report to MA DPH re: vaping-related lung disease [] Needs CXR in 6 weeks to document improvement . . # Nicotine dependence # Active smoking (tobacco/cigarettes) # Marijuana use (vaping THC using dab pen) Provided extensive counseling and motivational interviewing regarding cessation of both smoking and vaping. Patient demonstrated fair insight and seemed motivated to abstain from both smoking and vaping. We initiated both nicotine patch and gum while in the hospital. 14 mg patch was not enough, so went up to the 21 mg patch. She has dentures, so preferred the lozenge to the gum. On discharge, we prescribed both patch and lozenge and encouraged her to discuss potential medical treatment options to help her abstain from smoking with her PCP (e.g. buproprion or Chantix) [] Needs ongoing support w/ smoking cessation & possibly medication assistance . . # Anxiety Moderate anxiety while inpatient likely due to combination of cigarette smoking cessation, marijuana cessation, and significant social stressors. Treated w/ PRN hydroxyzine to good effect. . . # Anemia # B12 deficiency # Folate deficiency Was noted to have significant anemia (Hgb nadir of 9.5) that was relatively normocytic (MCV 95-97). Routine anemia labs revealed low Vit B12 and undetectable folate. She reported that she had received B12 shots earlier this year. MMA and homocysteine were ordered. Homocysteine was slightly elevated. MMA still pending at the time of discharge. TSH was wnl at 2.1. Ferritin and TSAT were not low to suggest concomitant iron deficiency. Treated with one dose of IM Vit B12, one dose of IV folic acid, and initiated on PO folic acid on discharge. [] Please recheck B12 & folate levels as appropriate and evaluate for underlying causes of these significant deficiencies if persistently low . . # Hx of cardiomyopathy: LVEF 40-45%. Thought to be post-partum. Held home metoprolol, lisinopril during hospitaliazation given SBPs frequently between 90-100. [] Please resume home cardiac meds at upcoming primary care appointment as long as BP not low . . . . Time in care: >45 minutes in discharge-related activities on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 224 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Famotidine 20 mg PO Q12H Duration: 20 Days Take until prednisone taper is complete. RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. GuaiFENesin-Dextromethorphan ___ mL PO Q6H:PRN Cough RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 10 ml by mouth q6h:PRN Refills:*0 4. Ipratropium-Albuterol Neb 1 NEB NEB ASDIR Duration: 8 Days Taper by 1 neb every 2 days: QID, QID, TID, TID, BID, BID, daily, daily, stop. RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 NEB INH ASDIR Disp #*20 Ampule Refills:*0 5. Nicotine Lozenge 4 mg PO Q1H:PRN cigarette craving RX *nicotine (polacrilex) 4 mg one 4 mg lozenge Q1H:PRN Disp #*60 Lozenge Refills:*3 6. Nicotine Patch 21 mg/day TD DAILY RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour (14) Apply 1 patch transdermally once a day Disp #*1 Box Refills:*0 7. PredniSONE 40 mg PO DAILY Duration: 5 Doses Start: Today - ___, First Dose: Next Routine Administration Time Taper as directed. This is dose # 1 of 4 tapered doses RX *prednisone 10 mg ASDIR tab by mouth once a day Disp #*50 Tablet Refills:*0 8. PredniSONE 30 mg PO DAILY Duration: 5 Doses Start: After 40 mg DAILY tapered dose Taper as directed. This is dose # 2 of 4 tapered doses 9. PredniSONE 20 mg PO DAILY Duration: 5 Doses Start: After 30 mg DAILY tapered dose Taper as directed. This is dose # 3 of 4 tapered doses 10. PredniSONE 10 mg PO DAILY Duration: 5 Doses Start: After 20 mg DAILY tapered dose Taper as directed. This is dose # 4 of 4 tapered doses 11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 12. Levothyroxine Sodium 224 mcg PO DAILY 13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 2 puffs BID RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation 2 puff INH twice a day Disp #*1 Inhaler Refills:*0 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed to do so by your PCP, ___ 16. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until instructed to do so by your PCP, ___ 17.Outpatient Physical Therapy Outpatient pulmonary rehabilitation Please evaluate and treat as needed for recent COPD exacerbation with acute hypoxic respiratory failure and vaping-induced lung injury. ICD-10: ___.1 Discharge Disposition: Home Discharge Diagnosis: # Vaping-induced lung disease # COPD exacerbation w/ acute hypoxic respiratory failure # Active smoking # Nicotine dependence # Anemia # B12 deficiency # Folate deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: T 98.2 PO BP 123/72 HR 79 RR 20 pOx 97% RA Ambulatory VS: RR 24 and pOx 91-94% on room air Gen: NAD HEENT: anicteric sclera, MMM Chest: mild inspiratory crackles over b/l mid-lung zones; no wheezing or rhonchi; expiratory phase not significant prolonged; +forceful coughing at times CV: RR, no m/r/g, 2+ distal pulses, no peripheral edema Abd: S/NT/ND, BS+ Neuro: awake, alert, conversant w/ clear speech, stable gait Discharge Instructions: Dear ___, You were admitted to the hospital with severe shortness of breath and hypoxia (low oxygen). We believe this was caused by a combination of your chronic lung disease (COPD from smoking) and recent vaping. Imaging studies showed inflammation of your lungs, but fortunately this improved with nebulizer treatments and steroids (prednisone). You were evaluated by the lung specialists who recommended a gradual taper of the prednisone and have contacted your primary lung doctor, ___, to help arrange a follow-up appointment. As we discussed, the most important thing you can do to prevent this from happening again is to not smoke cigarettes (or anything else) and do not vape. If you are going to use marijuana products, please consume edibles in safe amounts. In order to help you quit smoking and stay off cigarettes, you are being discharged on a nicotine patch as well as nicotine lozenges. Use the nicotine patch as instructed on the box. If you have a craving for a cigarette despite the nicotine patch, use the nicotine lozenges. Plan to talk with Dr. ___ at your upcoming appointment about how your efforts at quitting smoking are going and if any additional medications might be helpful. You were found to have anemia with low Vitamin B12 and low folic acid levels. You were given a B12 shot and a dose of IV folic acid prior to discharge. You should also take folic acid at home each day. Dr. ___ will follow up on your anemia and your low vitamin levels in clinic. Lastly, your home blood pressure medications (lisinopril and metoprolol) were not given during this hospitalization because your blood pressure was normal without them. We are holding these medications on discharge and you can discuss with Dr. ___ if you need to resume one or both of these medications in the future. It was a pleasure caring for you and we wish you a full and speedy recovery. Sincerely, Your ___ Medicine Team Followup Instructions: ___
[ "J8489", "J9601", "J45901", "J441", "I5022", "F17210", "T59811A", "J705", "Y929", "E039", "F419", "D513", "F1290", "R112", "E669", "Z6831", "Z801", "I110", "E876" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission labs: =============== [MASKED] 10:00PM BLOOD WBC-14.2* RBC-3.62* Hgb-11.2 Hct-34.2 MCV-95 MCH-30.9 MCHC-32.7 RDW-14.1 RDWSD-48.5* Plt [MASKED] [MASKED] 10:00PM BLOOD Neuts-91.7* Lymphs-5.4* Monos-1.7* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-13.05* AbsLymp-0.77* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.02 [MASKED] 10:00PM BLOOD Glucose-162* UreaN-6 Creat-0.7 Na-138 K-3.7 Cl-100 HCO3-22 AnGap-16 . . Notable labs: ============= [MASKED] 07:40AM BLOOD calTIBC-177* VitB12-162* Folate-<2 Hapto-374* Ferritn-317* TRF-136* [MASKED] 07:40AM BLOOD Homocys-16.6* [MASKED] 07:40AM BLOOD TSH-2.1 [MASKED] 07:40AM BLOOD METHYLMALONIC ACID-PENDING . . Micro: ======== -[MASKED] MRSA screen (nasal swab): pending -[MASKED] Urine strep pneumo antigen: pending -[MASKED] Urine legionella antigen: negative for serogroup 1 -[MASKED] Flu A&B PCR: negative -[MASKED] Respiratroy viral panel: pending -[MASKED] UCx: mixed bacterial flora (final) Imaging: ========= - CXR ([MASKED]): IMPRESSION: Findings concerning for multifocal pneumonia in the right lung. - [MASKED] CT chest w/ contrast: "IMPRESSION: 1. Diffuse ground-glass opacification throughout bilateral lungs in a peribronchovascular distribution. Differential considerations include atypical/viral infection, sarcoidosis, hypersensitivity pneumonitis, drug toxicity, or respiratory bronchiolitis interstitial lung disease given the history smoking. 2. Bilateral pulmonary nodules measuring up to 6 mm are stable dating back to [MASKED]. 3. Mild confluent bilateral hilar lymphadenopathy." . . Discharge labs: ================ [MASKED] 06:30AM BLOOD WBC-17.1* RBC-3.25* Hgb-10.1* Hct-31.6* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.2 RDWSD-50.3* Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-93 UreaN-7 Creat-0.7 Na-141 K-4.0 Cl-101 HCO3-26 AnGap-14 [MASKED] 06:30AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.9 Mg-2.0 . . Brief Hospital Course: [MASKED] smoker with history of cardiomyopathy, hypertension, asthma/COPD, prior desquamative interstitial pneumonia who presents with several weeks of cough and shortness of breath, found to have hypoxia. . . # Acute hypoxic respiratory failure # COPD exacerbation # Vaping-related lung disease -Hypoxia improved from 4L --> RA w/ prednisone 40 + standing duonebs + empiric abx -CT chest ([MASKED]) showing GGOs throughout b/l upper & middle lobes consistent with ILD and no evidence of consolidation to suggest PNA -Pulmonology was consulted, they felt that her presentation was most likely due to recent vaping. -Stopped Zosyn [MASKED] [MASKED] given no convincing evidence for bacterial pneumonia -No new fevers or worsening respiratory symptoms off abx -Ambulatory VS on day of discharge were RR 24 and pOx 91-94% on room air -Discharged on duoneb taper, prednisone taper (decrease by 10 mg every 5 days, per Pulm recs), with plans to follow-up with Dr. [MASKED] primary [MASKED] -FYI: we submitted confidential report to MA DPH re: vaping-related lung disease [] Needs CXR in 6 weeks to document improvement . . # Nicotine dependence # Active smoking (tobacco/cigarettes) # Marijuana use (vaping THC using dab pen) Provided extensive counseling and motivational interviewing regarding cessation of both smoking and vaping. Patient demonstrated fair insight and seemed motivated to abstain from both smoking and vaping. We initiated both nicotine patch and gum while in the hospital. 14 mg patch was not enough, so went up to the 21 mg patch. She has dentures, so preferred the lozenge to the gum. On discharge, we prescribed both patch and lozenge and encouraged her to discuss potential medical treatment options to help her abstain from smoking with her PCP (e.g. buproprion or Chantix) [] Needs ongoing support w/ smoking cessation & possibly medication assistance . . # Anxiety Moderate anxiety while inpatient likely due to combination of cigarette smoking cessation, marijuana cessation, and significant social stressors. Treated w/ PRN hydroxyzine to good effect. . . # Anemia # B12 deficiency # Folate deficiency Was noted to have significant anemia (Hgb nadir of 9.5) that was relatively normocytic (MCV 95-97). Routine anemia labs revealed low Vit B12 and undetectable folate. She reported that she had received B12 shots earlier this year. MMA and homocysteine were ordered. Homocysteine was slightly elevated. MMA still pending at the time of discharge. TSH was wnl at 2.1. Ferritin and TSAT were not low to suggest concomitant iron deficiency. Treated with one dose of IM Vit B12, one dose of IV folic acid, and initiated on PO folic acid on discharge. [] Please recheck B12 & folate levels as appropriate and evaluate for underlying causes of these significant deficiencies if persistently low . . # Hx of cardiomyopathy: LVEF 40-45%. Thought to be post-partum. Held home metoprolol, lisinopril during hospitaliazation given SBPs frequently between 90-100. [] Please resume home cardiac meds at upcoming primary care appointment as long as BP not low . . . . Time in care: >45 minutes in discharge-related activities on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 224 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN SOB 6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Famotidine 20 mg PO Q12H Duration: 20 Days Take until prednisone taper is complete. RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. GuaiFENesin-Dextromethorphan [MASKED] mL PO Q6H:PRN Cough RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 10 ml by mouth q6h:PRN Refills:*0 4. Ipratropium-Albuterol Neb 1 NEB NEB ASDIR Duration: 8 Days Taper by 1 neb every 2 days: QID, QID, TID, TID, BID, BID, daily, daily, stop. RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 NEB INH ASDIR Disp #*20 Ampule Refills:*0 5. Nicotine Lozenge 4 mg PO Q1H:PRN cigarette craving RX *nicotine (polacrilex) 4 mg one 4 mg lozenge Q1H:PRN Disp #*60 Lozenge Refills:*3 6. Nicotine Patch 21 mg/day TD DAILY RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour (14) Apply 1 patch transdermally once a day Disp #*1 Box Refills:*0 7. PredniSONE 40 mg PO DAILY Duration: 5 Doses Start: Today - [MASKED], First Dose: Next Routine Administration Time Taper as directed. This is dose # 1 of 4 tapered doses RX *prednisone 10 mg ASDIR tab by mouth once a day Disp #*50 Tablet Refills:*0 8. PredniSONE 30 mg PO DAILY Duration: 5 Doses Start: After 40 mg DAILY tapered dose Taper as directed. This is dose # 2 of 4 tapered doses 9. PredniSONE 20 mg PO DAILY Duration: 5 Doses Start: After 30 mg DAILY tapered dose Taper as directed. This is dose # 3 of 4 tapered doses 10. PredniSONE 10 mg PO DAILY Duration: 5 Doses Start: After 20 mg DAILY tapered dose Taper as directed. This is dose # 4 of 4 tapered doses 11. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN SOB 12. Levothyroxine Sodium 224 mcg PO DAILY 13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 2 puffs BID RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation 2 puff INH twice a day Disp #*1 Inhaler Refills:*0 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed to do so by your PCP, [MASKED] 16. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until instructed to do so by your PCP, [MASKED] 17.Outpatient Physical Therapy Outpatient pulmonary rehabilitation Please evaluate and treat as needed for recent COPD exacerbation with acute hypoxic respiratory failure and vaping-induced lung injury. ICD-10: [MASKED].1 Discharge Disposition: Home Discharge Diagnosis: # Vaping-induced lung disease # COPD exacerbation w/ acute hypoxic respiratory failure # Active smoking # Nicotine dependence # Anemia # B12 deficiency # Folate deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: T 98.2 PO BP 123/72 HR 79 RR 20 pOx 97% RA Ambulatory VS: RR 24 and pOx 91-94% on room air Gen: NAD HEENT: anicteric sclera, MMM Chest: mild inspiratory crackles over b/l mid-lung zones; no wheezing or rhonchi; expiratory phase not significant prolonged; +forceful coughing at times CV: RR, no m/r/g, 2+ distal pulses, no peripheral edema Abd: S/NT/ND, BS+ Neuro: awake, alert, conversant w/ clear speech, stable gait Discharge Instructions: Dear [MASKED], You were admitted to the hospital with severe shortness of breath and hypoxia (low oxygen). We believe this was caused by a combination of your chronic lung disease (COPD from smoking) and recent vaping. Imaging studies showed inflammation of your lungs, but fortunately this improved with nebulizer treatments and steroids (prednisone). You were evaluated by the lung specialists who recommended a gradual taper of the prednisone and have contacted your primary lung doctor, [MASKED], to help arrange a follow-up appointment. As we discussed, the most important thing you can do to prevent this from happening again is to not smoke cigarettes (or anything else) and do not vape. If you are going to use marijuana products, please consume edibles in safe amounts. In order to help you quit smoking and stay off cigarettes, you are being discharged on a nicotine patch as well as nicotine lozenges. Use the nicotine patch as instructed on the box. If you have a craving for a cigarette despite the nicotine patch, use the nicotine lozenges. Plan to talk with Dr. [MASKED] at your upcoming appointment about how your efforts at quitting smoking are going and if any additional medications might be helpful. You were found to have anemia with low Vitamin B12 and low folic acid levels. You were given a B12 shot and a dose of IV folic acid prior to discharge. You should also take folic acid at home each day. Dr. [MASKED] will follow up on your anemia and your low vitamin levels in clinic. Lastly, your home blood pressure medications (lisinopril and metoprolol) were not given during this hospitalization because your blood pressure was normal without them. We are holding these medications on discharge and you can discuss with Dr. [MASKED] if you need to resume one or both of these medications in the future. It was a pleasure caring for you and we wish you a full and speedy recovery. Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "J9601", "F17210", "Y929", "E039", "F419", "E669", "I110" ]
[ "J8489: Other specified interstitial pulmonary diseases", "J9601: Acute respiratory failure with hypoxia", "J45901: Unspecified asthma with (acute) exacerbation", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "I5022: Chronic systolic (congestive) heart failure", "F17210: Nicotine dependence, cigarettes, uncomplicated", "T59811A: Toxic effect of smoke, accidental (unintentional), initial encounter", "J705: Respiratory conditions due to smoke inhalation", "Y929: Unspecified place or not applicable", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "D513: Other dietary vitamin B12 deficiency anemia", "F1290: Cannabis use, unspecified, uncomplicated", "R112: Nausea with vomiting, unspecified", "E669: Obesity, unspecified", "Z6831: Body mass index [BMI] 31.0-31.9, adult", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "I110: Hypertensive heart disease with heart failure", "E876: Hypokalemia" ]
10,050,106
22,807,951
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cipro / Levaquin / Seroquel Attending: ___. Chief Complaint: agitated depression, possible psychosis on ___ from ER Major Surgical or Invasive Procedure: none History of Present Illness: Patient seen earlier this AM with RN, SW, Psych attending (___). History provided largely by husband who is at bedside. Son (___) is also present to provide information. ___ with agoraphobia, major depression, anxiety disorder, ___ disease brought to hospital by family because of acute on chronic worsening of outbursts of agtitation, paranoia, "psychosis". Episodes typically happen in late afternoon or evening, and she can become combative. She states just feels internally agitated and a need to physically release when these episodes happen. Husband reports poor sleep due to her needs of care. Son or daughter are often called to assist in calming her down. Was ___ in ER for geripsych eval and placement. Husband with some concern around her ___ control. Patient has otpt neurologist at ___ and a ___ neurologist (___), whom she hasn't seen in 1+ year (probably due to agoraphobia). Family has had little success with home health care takers and are getting burned out. They are concerned she get proper psych and neruo evaluations. ROS: (+) 40+lb weight loss last year. Poor appetite, food doesn't taste good. (+) anhedonia, worseining social isolation, doesn't go out. Denies abd pain, N/V, diarrhea, melena, hematochezia, anemia. Other 10pt systems are negative. Son shows me a video clip of one of her behavioral outbursts with husband getting upset. States father is a good person, but has a hard time separting himself from his wife for his own well-being. Past Medical History: Major depression - prior ECT Anxiety disorder Agoraphobia Parkinsons Social History: ___ Family History: Mo - depression Ma aunt - mental illness Physical Exam: Admission Exam (per admit note): AVSS Alert, oriented, though doesn't give most of history. Endorses poor memory and a dislike for memory tasks. Oriented to place. Well groomed HEENT - anicteric, OP clear, neck supple ___ about head/neck/axilla LUNGS CTA bilat COR RRR no MRG ABD soft NT/ND no HSM or masses EXT no edema SKIN no lesions NEURO alert, fluent speech. During our visit, she is appropriate. Moves all extremities w/o difficulty, sits up unassisted, no tremor, scant cog-wheel (is 1 hr overdue for her q2 sinemet) PSYCH appears anxious at times, defers a lot of interaction to her husband, feels calm at the time of our interview Discharge Exam: Vital Signs: AFVSS GEN: Alert, NAD HEENT: NC/AT CV: RRR, no m/r/g PULM: CTA B GI: S/NT/ND, BS present NEURO: Oriented to ___, thought it was ___ MAE; no cogwheeling noted PSYCH: calm and appropriate Pertinent Results: ___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 03:00PM URINE HOURS-RANDOM ___ 01:30PM GLUCOSE-126* UREA N-9 CREAT-0.7 SODIUM-132* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16 ___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 01:30PM WBC-7.9 RBC-4.15 HGB-12.9 HCT-38.3 MCV-92 MCH-31.1 MCHC-33.7 RDW-11.9 RDWSD-39.8 ___ 01:30PM NEUTS-73.4* LYMPHS-16.3* MONOS-8.5 EOS-0.9* BASOS-0.5 IM ___ AbsNeut-5.82 AbsLymp-1.29 AbsMono-0.67 AbsEos-0.07 AbsBaso-0.04 ___ 01:30PM PLT COUNT-270 ___ CXR IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: ___ wth depression, anxiety, agoraphobia, ___ disease referred and admitted for increasingly agitated behavioural outbursts (yells, throws items), chronic weight loss and failure to thrive at home. Concerning for worsenging underlying psychiatric conditions +/- Parkinsons medication difficulty. Patient family with significant caregiver stress. Pt was seen by neuro and psych inpatient consult services, who were also in touch with her outpatient providers. Mental status reportedly improved with decreased Sinemet dosing. Here in hospital, her behavioral stress and outbursts tend to occur when her husband is here or just after he leaves. Was initially placed on ___, but this was ultiamtely lifted. Patient was offered inpatient psych admission. However, she and her husband initially declined this. Pt and family now considering ___ unit at ___, will pursue this after discharge. Pt was discharged on decreased regimen of Sinemet. She had been stable on this regimen in house for several days prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 1 mg PO ASDIR 2. Carbidopa-Levodopa (___) 1 TAB PO ASDIR 3. TraZODone 100 mg PO QHS 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY 3. TraZODone 100 mg PO QHS 4. Carbidopa-Levodopa (___) 1 TAB PO TID Give at 10:30a, 16:30a, 19:30p. RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Carbidopa-Levodopa (___) 1.5 TAB PO BID Give at 7:30a and 13:30. RX *carbidopa-levodopa 25 mg-100 mg 1.5 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 6. Carbidopa-Levodopa (___) 1 TAB PO Q2H:PRN parkinsons Between 00:00a and 6:30a, may give 1 tablet for ___ symptoms q2hrprn up to 3 doses. RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth q2h Disp #*30 Tablet Refills:*0 7. Diazepam 1 mg PO DAILY Give at 8:00a. RX *diazepam 2 mg 0.5 (One half) tablet by mouth in the morning Disp #*15 Tablet Refills:*0 8. Diazepam 2 mg PO BID Give at 14:30p and at 20:30p RX *diazepam 2 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Major depression, unspecified Agoraphobia w/ panic disorder Parkinsonism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with progressive anxiety, agitation, depression, and failure to thrive. You were seen by psychiatry as well as neurology. Your Sinemet was adjusted, and your agitation improved without worsening of Parkinsonism. A team meeting was held to determine the best paln for you / your family going forward. You are being discharged home with plans for further treatment at the ___ psychiatry unit (your husband is working to arrange this). Followup Instructions: ___
[ "F332", "G20", "E871", "R627", "F419", "F4001", "R634", "Z6821", "Z818" ]
Allergies: Penicillins / Cipro / Levaquin / Seroquel Chief Complaint: agitated depression, possible psychosis on [MASKED] from ER Major Surgical or Invasive Procedure: none History of Present Illness: Patient seen earlier this AM with RN, SW, Psych attending ([MASKED]). History provided largely by husband who is at bedside. Son ([MASKED]) is also present to provide information. [MASKED] with agoraphobia, major depression, anxiety disorder, [MASKED] disease brought to hospital by family because of acute on chronic worsening of outbursts of agtitation, paranoia, "psychosis". Episodes typically happen in late afternoon or evening, and she can become combative. She states just feels internally agitated and a need to physically release when these episodes happen. Husband reports poor sleep due to her needs of care. Son or daughter are often called to assist in calming her down. Was [MASKED] in ER for geripsych eval and placement. Husband with some concern around her [MASKED] control. Patient has otpt neurologist at [MASKED] and a [MASKED] neurologist ([MASKED]), whom she hasn't seen in 1+ year (probably due to agoraphobia). Family has had little success with home health care takers and are getting burned out. They are concerned she get proper psych and neruo evaluations. ROS: (+) 40+lb weight loss last year. Poor appetite, food doesn't taste good. (+) anhedonia, worseining social isolation, doesn't go out. Denies abd pain, N/V, diarrhea, melena, hematochezia, anemia. Other 10pt systems are negative. Son shows me a video clip of one of her behavioral outbursts with husband getting upset. States father is a good person, but has a hard time separting himself from his wife for his own well-being. Past Medical History: Major depression - prior ECT Anxiety disorder Agoraphobia Parkinsons Social History: [MASKED] Family History: Mo - depression Ma aunt - mental illness Physical Exam: Admission Exam (per admit note): AVSS Alert, oriented, though doesn't give most of history. Endorses poor memory and a dislike for memory tasks. Oriented to place. Well groomed HEENT - anicteric, OP clear, neck supple [MASKED] about head/neck/axilla LUNGS CTA bilat COR RRR no MRG ABD soft NT/ND no HSM or masses EXT no edema SKIN no lesions NEURO alert, fluent speech. During our visit, she is appropriate. Moves all extremities w/o difficulty, sits up unassisted, no tremor, scant cog-wheel (is 1 hr overdue for her q2 sinemet) PSYCH appears anxious at times, defers a lot of interaction to her husband, feels calm at the time of our interview Discharge Exam: Vital Signs: AFVSS GEN: Alert, NAD HEENT: NC/AT CV: RRR, no m/r/g PULM: CTA B GI: S/NT/ND, BS present NEURO: Oriented to [MASKED], thought it was [MASKED] MAE; no cogwheeling noted PSYCH: calm and appropriate Pertinent Results: [MASKED] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 03:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 03:00PM URINE HOURS-RANDOM [MASKED] 01:30PM GLUCOSE-126* UREA N-9 CREAT-0.7 SODIUM-132* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16 [MASKED] 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [MASKED] 01:30PM WBC-7.9 RBC-4.15 HGB-12.9 HCT-38.3 MCV-92 MCH-31.1 MCHC-33.7 RDW-11.9 RDWSD-39.8 [MASKED] 01:30PM NEUTS-73.4* LYMPHS-16.3* MONOS-8.5 EOS-0.9* BASOS-0.5 IM [MASKED] AbsNeut-5.82 AbsLymp-1.29 AbsMono-0.67 AbsEos-0.07 AbsBaso-0.04 [MASKED] 01:30PM PLT COUNT-270 [MASKED] CXR IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: [MASKED] wth depression, anxiety, agoraphobia, [MASKED] disease referred and admitted for increasingly agitated behavioural outbursts (yells, throws items), chronic weight loss and failure to thrive at home. Concerning for worsenging underlying psychiatric conditions +/- Parkinsons medication difficulty. Patient family with significant caregiver stress. Pt was seen by neuro and psych inpatient consult services, who were also in touch with her outpatient providers. Mental status reportedly improved with decreased Sinemet dosing. Here in hospital, her behavioral stress and outbursts tend to occur when her husband is here or just after he leaves. Was initially placed on [MASKED], but this was ultiamtely lifted. Patient was offered inpatient psych admission. However, she and her husband initially declined this. Pt and family now considering [MASKED] unit at [MASKED], will pursue this after discharge. Pt was discharged on decreased regimen of Sinemet. She had been stable on this regimen in house for several days prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 1 mg PO ASDIR 2. Carbidopa-Levodopa ([MASKED]) 1 TAB PO ASDIR 3. TraZODone 100 mg PO QHS 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY 3. TraZODone 100 mg PO QHS 4. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID Give at 10:30a, 16:30a, 19:30p. RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO BID Give at 7:30a and 13:30. RX *carbidopa-levodopa 25 mg-100 mg 1.5 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 6. Carbidopa-Levodopa ([MASKED]) 1 TAB PO Q2H:PRN parkinsons Between 00:00a and 6:30a, may give 1 tablet for [MASKED] symptoms q2hrprn up to 3 doses. RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth q2h Disp #*30 Tablet Refills:*0 7. Diazepam 1 mg PO DAILY Give at 8:00a. RX *diazepam 2 mg 0.5 (One half) tablet by mouth in the morning Disp #*15 Tablet Refills:*0 8. Diazepam 2 mg PO BID Give at 14:30p and at 20:30p RX *diazepam 2 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Major depression, unspecified Agoraphobia w/ panic disorder Parkinsonism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with progressive anxiety, agitation, depression, and failure to thrive. You were seen by psychiatry as well as neurology. Your Sinemet was adjusted, and your agitation improved without worsening of Parkinsonism. A team meeting was held to determine the best paln for you / your family going forward. You are being discharged home with plans for further treatment at the [MASKED] psychiatry unit (your husband is working to arrange this). Followup Instructions: [MASKED]
[]
[ "E871", "F419" ]
[ "F332: Major depressive disorder, recurrent severe without psychotic features", "G20: Parkinson's disease", "E871: Hypo-osmolality and hyponatremia", "R627: Adult failure to thrive", "F419: Anxiety disorder, unspecified", "F4001: Agoraphobia with panic disorder", "R634: Abnormal weight loss", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z818: Family history of other mental and behavioral disorders" ]
10,050,445
25,137,144
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with a history of afib on xarelto who presents with a fall with a left SDH, repeat scan showing right frontal contusion, left temporal contusion, and bilateral SAH Past Medical History: Atrial fibrillation (HCC) CHF (congestive heart failure) (___) Diabetes mellitus (___) High cholesterol Hypertension Prediabetes Dyslipidemia Typical atrial flutter (HCC) Abdominal aortic aneurysm without rupture (HCC) Pharyngoesophageal dysphagia Disturbance of salivary secretion Hypovitaminosis D Pleural plaque Cognitive impairment Tobacco use disorder Laryngopharyngeal reflux (LPR) At risk for falls Non-rheumatic mitral regurgitation Social History: ___ Family History: NC Physical Exam: On admission: =========================== GCS in ED 15 HEENT: Abrasion to left lateral head, otherwise atraumatic Neck: In a C-collar, otherwise supple Extrem: warm and well perfused Neuro: Mental Status: Somnolent, but opens eyes quickly to voice. Awake, alert, cooperative throughout exam, normal affect. Extremely hard of hearing. Orientation: Oriented to self, tangential speech as answers to other questions. Language: Speech is fluent with receptive aphasia. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements grossly 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. Moves all extremities against resistance, but does not follow complex motor exam. Sensation: Withdraws to light touch in all extremities. ==================================== At Discharge: ==================================== Expired Pertinent Results: Please see the OMR for pertinent results. Brief Hospital Course: #Subarachnoid hemorrhage/bilateral IPH Following emergency department evaluation and imaging demonstrating multiple areas of bleeding without midline shift, the patient was admitted to the Neuro ICU. He was started on Keppra and made NPO, with regular neuro checks. He had a repeat CT scan the following morning to assess interval changes, which demonstrated an increased size of hemorrhagic contusions with increased surrounding edema, as well as mild mass effect with rightward movement of the left uncus but without clear uncal herniation. The patient was followed closely with repeat head CT's, which showed expansion of the intracranial bleeds. On ___, a family meeting was held and it was determined that he patient would be extubated the following day if his exam does not improve. On ___, he was extubated. He expired on ___. Medications on Admission: Medications at home: -cephALEXin (KEFLEX) 500 MG capsule Take 1 capsule by mouth 4 (four) times daily -atorvastatin (LIPITOR) 40 MG tablet Take 1 tablet by mouth daily -fluticasone (FLONASE) 50 MCG/ACT nasal spray 2 sprays by Each Nostril route daily -rivaroxaban (XARELTO) 20 MG TABS Take 1 tablet by mouth daily with dinner -furosemide (LASIX) 20 MG tablet take 1 tablet by mouth once daily -metFORMIN (GLUCOPHAGE) 500 MG tablet take 1 tablet by mouth twice a day with meals -ergocalciferol (VITAMIN D2) ___ UNIT capsule Take 1 capsule by mouth once a week -erythromycin (ROMYCIN) ophthalmic ointment -losartan (COZAAR) 50 MG tablet take 1 tablet by mouth once daily -digoxin (DIGITEK) 0.125 MG tablet Take 1 tablet by mouth daily -carvedilol (COREG) 3.125 MG tablet Take 1 tablet by mouth 2 (two) times daily with meals -latanoprost (XALATAN) 0.005 % ophthalmic solution -potassium chloride (KLOR-CON) ___ MEQ packet Take 40 mEq by mouth 2 (two) times daily Discharge Medications: none - expired Discharge Disposition: Expired Discharge Diagnosis: Right frontal IPH, left temporal IPH Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: ___
[ "S065X9A", "I4892", "I5020", "S066X9A", "S062X9A", "W109XXA", "F17210", "E785", "I4891", "I110", "R402141", "R402361", "R402251", "Z515", "Z781" ]
Allergies: No Allergies/ADRs on File Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] year old male with a history of afib on xarelto who presents with a fall with a left SDH, repeat scan showing right frontal contusion, left temporal contusion, and bilateral SAH Past Medical History: Atrial fibrillation (HCC) CHF (congestive heart failure) ([MASKED]) Diabetes mellitus ([MASKED]) High cholesterol Hypertension Prediabetes Dyslipidemia Typical atrial flutter (HCC) Abdominal aortic aneurysm without rupture (HCC) Pharyngoesophageal dysphagia Disturbance of salivary secretion Hypovitaminosis D Pleural plaque Cognitive impairment Tobacco use disorder Laryngopharyngeal reflux (LPR) At risk for falls Non-rheumatic mitral regurgitation Social History: [MASKED] Family History: NC Physical Exam: On admission: =========================== GCS in ED 15 HEENT: Abrasion to left lateral head, otherwise atraumatic Neck: In a C-collar, otherwise supple Extrem: warm and well perfused Neuro: Mental Status: Somnolent, but opens eyes quickly to voice. Awake, alert, cooperative throughout exam, normal affect. Extremely hard of hearing. Orientation: Oriented to self, tangential speech as answers to other questions. Language: Speech is fluent with receptive aphasia. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements grossly 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. Moves all extremities against resistance, but does not follow complex motor exam. Sensation: Withdraws to light touch in all extremities. ==================================== At Discharge: ==================================== Expired Pertinent Results: Please see the OMR for pertinent results. Brief Hospital Course: #Subarachnoid hemorrhage/bilateral IPH Following emergency department evaluation and imaging demonstrating multiple areas of bleeding without midline shift, the patient was admitted to the Neuro ICU. He was started on Keppra and made NPO, with regular neuro checks. He had a repeat CT scan the following morning to assess interval changes, which demonstrated an increased size of hemorrhagic contusions with increased surrounding edema, as well as mild mass effect with rightward movement of the left uncus but without clear uncal herniation. The patient was followed closely with repeat head CT's, which showed expansion of the intracranial bleeds. On [MASKED], a family meeting was held and it was determined that he patient would be extubated the following day if his exam does not improve. On [MASKED], he was extubated. He expired on [MASKED]. Medications on Admission: Medications at home: -cephALEXin (KEFLEX) 500 MG capsule Take 1 capsule by mouth 4 (four) times daily -atorvastatin (LIPITOR) 40 MG tablet Take 1 tablet by mouth daily -fluticasone (FLONASE) 50 MCG/ACT nasal spray 2 sprays by Each Nostril route daily -rivaroxaban (XARELTO) 20 MG TABS Take 1 tablet by mouth daily with dinner -furosemide (LASIX) 20 MG tablet take 1 tablet by mouth once daily -metFORMIN (GLUCOPHAGE) 500 MG tablet take 1 tablet by mouth twice a day with meals -ergocalciferol (VITAMIN D2) [MASKED] UNIT capsule Take 1 capsule by mouth once a week -erythromycin (ROMYCIN) ophthalmic ointment -losartan (COZAAR) 50 MG tablet take 1 tablet by mouth once daily -digoxin (DIGITEK) 0.125 MG tablet Take 1 tablet by mouth daily -carvedilol (COREG) 3.125 MG tablet Take 1 tablet by mouth 2 (two) times daily with meals -latanoprost (XALATAN) 0.005 % ophthalmic solution -potassium chloride (KLOR-CON) [MASKED] MEQ packet Take 40 mEq by mouth 2 (two) times daily Discharge Medications: none - expired Discharge Disposition: Expired Discharge Diagnosis: Right frontal IPH, left temporal IPH Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: [MASKED]
[]
[ "F17210", "E785", "I4891", "I110", "Z515" ]
[ "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "I4892: Unspecified atrial flutter", "I5020: Unspecified systolic (congestive) heart failure", "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S062X9A: Diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "I4891: Unspecified atrial fibrillation", "I110: Hypertensive heart disease with heart failure", "R402141: Coma scale, eyes open, spontaneous, in the field [EMT or ambulance]", "R402361: Coma scale, best motor response, obeys commands, in the field [EMT or ambulance]", "R402251: Coma scale, best verbal response, oriented, in the field [EMT or ambulance]", "Z515: Encounter for palliative care", "Z781: Physical restraint status" ]
10,050,755
20,050,796
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever, encephalopathy, hypernatremia Major Surgical or Invasive Procedure: none History of Present Illness: ___ ___, history of left multifocal MCA/PCA hemispheric stroke, chronic, bilateral upper and lower contractures, HTN, hyperlipidemia, malnutrition on G-tube feedings, h/o PPD (+) unclear if ever treated, with recent admissions ___ and ___ for asperation pneumonia (treated broadly then with Augmentin), encephalopathy, hypernatremia sent in from ___ with decline in mental status, respiratory distress this AM, and hypernatremia. The patient has baseline aphasia and R sided weakness but was less attentive today than usual and was tachypneic earlier today. He has had hypernatremia in recent days to 160 at SNF. He was unable to provide additional history. Daughter is unsatisfied with care he is receiving at current facility. In the ER he was responsive to tactile stimulation only. He spiked a fever to 101.8 for which was given IV Vanco/Zosyn, and 2 x IV NS 500cc. His sodium was 149-->153. A CXR showed interval resolution of RUL opacity but persistent Left infiltrate concerning for infection. A lactate was 2.1. A foley catheter was placed and urine was benign. Last VS in ER 101.8 --> 100.2, 73, 112/45, 20 98% on RA Past Medical History: - Pneumonitis due to inhalation of food and vomit - Metabolic encephalopathy - ___ disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory ___ - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids - Essential HTN Dysphagia following CVA Generalized muscle weakness Gastrostomy status Social History: ___ Family History: No known cancer in the family Physical Exam: 97.8, 133/59, 85, 20, 100%3L Thin elderly, malnourished man, with chronic bilat UEx/LEx contractures HEENT - bitemp wasting, OP dry, neck supple, no ___ LUNGS - tubular breath sounds anterior apical, COR - RRR on MRG ABD - thin, G-tube in place C/D/I, no HSM, no R/G EXT - no edema SKIN - stage II decub large coccyx, and small R hip NEURO - chronic contractures, no response to voice, though makes eye contact, R flaccid paralysis RUEx PSYCH - calma Pertinent Results: ___ 02:42PM WBC-14.7*# RBC-3.57* HGB-11.1* HCT-36.7*# MCV-103* MCH-31.1 MCHC-30.2* RDW-16.3* RDWSD-60.6* ___ 02:42PM PLT COUNT-251 ___ 02:42PM NEUTS-83.2* LYMPHS-9.5* MONOS-4.8* EOS-1.5 BASOS-0.3 IM ___ AbsNeut-12.21* AbsLymp-1.39 AbsMono-0.71 AbsEos-0.22 AbsBaso-0.05 ___ 02:42PM ___ PTT-27.2 ___ ___ 02:57PM LACTATE-1.6 NA+-153* K+-4.6 CL--113* ___ 02:42PM GLUCOSE-169* UREA N-48* CREAT-0.8 SODIUM-149* POTASSIUM-4.8 CHLORIDE-114* TOTAL CO2-30 ANION GAP-10 ___ 02:42PM CALCIUM-8.5 PHOSPHATE-4.6*# MAGNESIUM-2.1 ___ 04:06PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 BCx x 2 sets: pending UCX : pending CXR (AP): Continued interval resolution of the parenchymal opacity on the right with stable parenchymal opacity on the left worrisome for infection. Brief Hospital Course: ___ ___, history of left multifocal MCA/PCA hemispheric stroke, chronic, bilateral upper and lower contractures, HTN, hyperlipidemia, malnutrition, h/o (+) PPD but unclear if ever treated with INH, on G-tube feedings, with recent admissions ___ and ___ for asperation pneumonia, encephalopathy, hypernatremia sent in from ___ with decline in mental status, respiratory distress this AM (now resolved), new hypoxemia, hypernatremia, and CXR with persistent LUL opacification concerning for infection. He was febrile in the ED and altered but became slightly more responsive with IV fluids and IV vancomycin and zosyn. Per the hospitalist, thirty minutes after reaching the floor (~1230 ___ he became less responsive and developed stridor with increased accessory muscle use with breathing. ICU team was paged to evaluate the patient. He was found to have loud audible stridor but was still satting 100% on non rebreather. He was transferred tot he ___ ICU. In the FICU, we attempted to inspect his mouth to identify any sources of obstruction. This was difficult as he clamped down his mouth. He became progressively hypoxic and then bradycardic going into asystole at 1am. An oral airway was placed, and the team began CPR. Anesthesia placed an ET tube. Per their note: They felt stiff lungs with bag ventilation that slightly improved with aggressive suctioning (pulled back blood, "tissue like" mass and fluids). A bronchoscopy was performed with "tissue-like" mass distal to the ETT. O2 sats remained 70-80%. He received 5 cycles of CPR and 5 pushes of epinephrine with only PEA or asystole on pulse/rhythm check. He was declared deceased at 1:26am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO/NG DAILY 2. Carbidopa-Levodopa (___) 1 TAB PO/NG TID 3. Clopidogrel 75 mg PO DAILY 4. Atorvastatin 80 mg PO/NG QPM 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. Senna 8.6 mg PO/NG DAILY:PRN constipation 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. Acetaminophen 650 mg PO/NG Q6H:PRN pain Discharge Disposition: Expired Discharge Diagnosis: Hypoxemic respiratory failure PEA arrest Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: ___
[ "J189", "J9691", "E43", "E870", "G92", "G20", "R1310", "I69351", "I69391", "E46", "I469", "I10", "E785", "J988" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fever, encephalopathy, hypernatremia Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] [MASKED], history of left multifocal MCA/PCA hemispheric stroke, chronic, bilateral upper and lower contractures, HTN, hyperlipidemia, malnutrition on G-tube feedings, h/o PPD (+) unclear if ever treated, with recent admissions [MASKED] and [MASKED] for asperation pneumonia (treated broadly then with Augmentin), encephalopathy, hypernatremia sent in from [MASKED] with decline in mental status, respiratory distress this AM, and hypernatremia. The patient has baseline aphasia and R sided weakness but was less attentive today than usual and was tachypneic earlier today. He has had hypernatremia in recent days to 160 at SNF. He was unable to provide additional history. Daughter is unsatisfied with care he is receiving at current facility. In the ER he was responsive to tactile stimulation only. He spiked a fever to 101.8 for which was given IV Vanco/Zosyn, and 2 x IV NS 500cc. His sodium was 149-->153. A CXR showed interval resolution of RUL opacity but persistent Left infiltrate concerning for infection. A lactate was 2.1. A foley catheter was placed and urine was benign. Last VS in ER 101.8 --> 100.2, 73, 112/45, 20 98% on RA Past Medical History: - Pneumonitis due to inhalation of food and vomit - Metabolic encephalopathy - [MASKED] disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory [MASKED] - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids - Essential HTN Dysphagia following CVA Generalized muscle weakness Gastrostomy status Social History: [MASKED] Family History: No known cancer in the family Physical Exam: 97.8, 133/59, 85, 20, 100%3L Thin elderly, malnourished man, with chronic bilat UEx/LEx contractures HEENT - bitemp wasting, OP dry, neck supple, no [MASKED] LUNGS - tubular breath sounds anterior apical, COR - RRR on MRG ABD - thin, G-tube in place C/D/I, no HSM, no R/G EXT - no edema SKIN - stage II decub large coccyx, and small R hip NEURO - chronic contractures, no response to voice, though makes eye contact, R flaccid paralysis RUEx PSYCH - calma Pertinent Results: [MASKED] 02:42PM WBC-14.7*# RBC-3.57* HGB-11.1* HCT-36.7*# MCV-103* MCH-31.1 MCHC-30.2* RDW-16.3* RDWSD-60.6* [MASKED] 02:42PM PLT COUNT-251 [MASKED] 02:42PM NEUTS-83.2* LYMPHS-9.5* MONOS-4.8* EOS-1.5 BASOS-0.3 IM [MASKED] AbsNeut-12.21* AbsLymp-1.39 AbsMono-0.71 AbsEos-0.22 AbsBaso-0.05 [MASKED] 02:42PM [MASKED] PTT-27.2 [MASKED] [MASKED] 02:57PM LACTATE-1.6 NA+-153* K+-4.6 CL--113* [MASKED] 02:42PM GLUCOSE-169* UREA N-48* CREAT-0.8 SODIUM-149* POTASSIUM-4.8 CHLORIDE-114* TOTAL CO2-30 ANION GAP-10 [MASKED] 02:42PM CALCIUM-8.5 PHOSPHATE-4.6*# MAGNESIUM-2.1 [MASKED] 04:06PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 BCx x 2 sets: pending UCX : pending CXR (AP): Continued interval resolution of the parenchymal opacity on the right with stable parenchymal opacity on the left worrisome for infection. Brief Hospital Course: [MASKED] [MASKED], history of left multifocal MCA/PCA hemispheric stroke, chronic, bilateral upper and lower contractures, HTN, hyperlipidemia, malnutrition, h/o (+) PPD but unclear if ever treated with INH, on G-tube feedings, with recent admissions [MASKED] and [MASKED] for asperation pneumonia, encephalopathy, hypernatremia sent in from [MASKED] with decline in mental status, respiratory distress this AM (now resolved), new hypoxemia, hypernatremia, and CXR with persistent LUL opacification concerning for infection. He was febrile in the ED and altered but became slightly more responsive with IV fluids and IV vancomycin and zosyn. Per the hospitalist, thirty minutes after reaching the floor (~1230 [MASKED] he became less responsive and developed stridor with increased accessory muscle use with breathing. ICU team was paged to evaluate the patient. He was found to have loud audible stridor but was still satting 100% on non rebreather. He was transferred tot he [MASKED] ICU. In the FICU, we attempted to inspect his mouth to identify any sources of obstruction. This was difficult as he clamped down his mouth. He became progressively hypoxic and then bradycardic going into asystole at 1am. An oral airway was placed, and the team began CPR. Anesthesia placed an ET tube. Per their note: They felt stiff lungs with bag ventilation that slightly improved with aggressive suctioning (pulled back blood, "tissue like" mass and fluids). A bronchoscopy was performed with "tissue-like" mass distal to the ETT. O2 sats remained 70-80%. He received 5 cycles of CPR and 5 pushes of epinephrine with only PEA or asystole on pulse/rhythm check. He was declared deceased at 1:26am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO/NG DAILY 2. Carbidopa-Levodopa ([MASKED]) 1 TAB PO/NG TID 3. Clopidogrel 75 mg PO DAILY 4. Atorvastatin 80 mg PO/NG QPM 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. Senna 8.6 mg PO/NG DAILY:PRN constipation 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. Acetaminophen 650 mg PO/NG Q6H:PRN pain Discharge Disposition: Expired Discharge Diagnosis: Hypoxemic respiratory failure PEA arrest Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: [MASKED]
[]
[ "I10", "E785" ]
[ "J189: Pneumonia, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "E43: Unspecified severe protein-calorie malnutrition", "E870: Hyperosmolality and hypernatremia", "G92: Toxic encephalopathy", "G20: Parkinson's disease", "R1310: Dysphagia, unspecified", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I69391: Dysphagia following cerebral infarction", "E46: Unspecified protein-calorie malnutrition", "I469: Cardiac arrest, cause unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J988: Other specified respiratory disorders" ]
10,050,755
20,724,333
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath and choking Major Surgical or Invasive Procedure: none History of Present Illness: ___ male with ___, history of left hemispheric stroke, hypertension, and hyperlipidemia with recent admission for pneumonia and multifocal CVA presents from rehab with a change in mental status, seating and coudhing with audible crackles shortness of breath. History limited but his dtr reports that she was with the pt when she tried to remove a solid piece of ?food from his mouth with her finger wrapped in a paper napkin. After doing this she noted him to have some respiratory distress and noted him to "be choking" and needing suction. She reports the staff at the rehab stated they could not suction him without a doctors ___. Has been wearing o2 at baseline, 2L the patient had an episode of vomiting this evening at rehab followed by difficulty breathing and hypoxia. He received neb treatments with some improvement but they are unable to suction him at rehab so the daughter requested transfer to the ED . In ER: (Triage Vitals: unable |96.1 |86 |128/73 |20 |96% Nasal Cannula ) Meds Given: ___ 00:39 IV Vancomycin 1000 mg Fluids given: None Radiology Studies: None consults called. None . PAIN SCALE: ___ per patient He did report to her a few days ago shortness of breath. She has noticed however that during the course of his rehab his breathing has improved. He was last home in ___ and walked to his appointments in ___. All other limited ROS negative as above. Past Medical History: - Pneumonitis due to inhalation of food and vomit - Metabolic encephalopathy - ___ disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory ___ - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids - Essential HTN Dysphagia following CVA Generalized muscle weakness Gastrostomy status Social History: ___ Family History: Per his dtr his parents died of natural causes. She cannot tell me how old they were when they died. Physical Exam: ADMISSION EXAM: Vitals: T 98.3 P 95 BP 115/68 RR 18 SaO2 96% 2L CONS: Thin, elderly gentleman NAD, contracted, + temporal wasting HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: Crackles at the bases b/l GI: G tube site, C/D/I, no rebound or guarding GU: normal genetalia MSK:no c/c/e 2+pulses SKIN: stage II decubitus NEURO: contracted b/l upper extremities, he does not appear to respond to voice, He tries to swat our hands away when we turn him PSYCH: calm, cooperative LAD: No cervical LAD DISCHARGE EXAM: Vital Signs: 98.5 138/57 70 24 92%RA GEN: Alert, opens eyes to voice but does not answer questions, pushing me away when I attempt to examine him HEENT: NC/AT, masked facies CV: RRR, no m/r/g PULM: CTA on anterior auscultation, somewhat limited exam as patient keeps pushing me away GI: soft, BS present, no apparent tenderness, G-tube present EXT: no ___ edema noted NEURO: Notable rigidity throughout, otherwise largely not cooperative with exam (does continue to push me away with left hand) Pertinent Results: Admission Labs: ___ 08:50PM BLOOD WBC-11.8*# RBC-3.14* Hgb-9.7* Hct-31.4* MCV-100* MCH-30.9 MCHC-30.9* RDW-16.0* RDWSD-58.4* Plt ___ ___ 08:50PM BLOOD Neuts-80.1* Lymphs-10.9* Monos-6.7 Eos-1.5 Baso-0.3 Im ___ AbsNeut-9.42* AbsLymp-1.28 AbsMono-0.79 AbsEos-0.18 AbsBaso-0.04 ___ 08:50PM BLOOD Glucose-116* UreaN-36* Creat-0.8 Na-141 K-6.8* Cl-108 HCO3-22 AnGap-18 ___ 08:50PM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9 Discharge Labs: ___ 06:10AM BLOOD WBC-6.3 RBC-2.90* Hgb-9.0* Hct-28.6* MCV-99* MCH-31.0 MCHC-31.5* RDW-15.4 RDWSD-56.0* Plt ___ ___ 06:10AM BLOOD Glucose-127* UreaN-30* Creat-0.8 Na-142 K-4.3 Cl-108 HCO3-26 AnGap-12 ___ 06:10AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2 Other Labs: ___ 08:50PM BLOOD proBNP-457 ___ 08:57PM BLOOD Lactate-1.4 K-6.0* Blood Cx x ___ - ___ 8:50 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___, ___ @ 23:54 (___). Blood Cx x 3 PENDING, w/ NGTD URINE Legionella Antigen NEGATIVE MRSA Screen negative ECG - Sinus rhythm. Baseline artifact. Increase in rate as compared with prior ECG ___. Low limb lead voltage. Compared to the previous tracing no diagnostic interim change. CXR - FINDINGS: AP upright and lateral views of the chest provided. There is new consolidation in the left mid to upper lung which is concerning for pneumonia. Coarsened markings in the lower lungs may reflect sequelae of chronic aspiration. Right upper lobe appears partially collapsed. Cardiomediastinal silhouette is unchanged. IMPRESSION: Findings concerning for new pneumonia in the left mid lung. Brief Hospital Course: ___ y/o M with PMHx of HTN, HLD, prior CVA in ___, ___, recurrent aspiration, who presented from rehab with cough, shortness of breath, confusion. This occurred ? after an episode of emesis. In the ED, imaging was concerning for PNA. He was admitted for tx of PNA. # Aspiration PNA: Breathing comfortably. Lungs clear on anterior auscultation. Given seemingly sudden-onset of respiratory distress followed by rapid improvement, this raises the question of whether patient has true aspiration PNA vs. aspiration pneumonitis. She was initially treated with broad regimen of vanc / cefepime / levofloxacin. Given rapid clinical improvement, abx were narrowed to Augmentin monotherapy, and pt remains stable on this regimen. Plan is to continue for a total 7 day course of abx for aspiration PNA (last day ___. # + Blood Cx: Suspect contaminant. 1 blood cx with CONS, no other positive blood cx. # ___ Disease: On home carbidopa/levodopa. # HLD: On home statin. # Prior CVA: On ASA/Plavix. # Severe Malnutrition: On tube feeds, nutrition c/s following. TRANSITIONAL ISSUES: - Continue Augmentin regimen until ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Carbidopa-Levodopa (___) 1 TAB PO TID 5. Atorvastatin 80 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Acetaminophen 650 mg PO Q6H:PRN fever or pain 8. Aspirin 81 mg PO DAILY 9. Bisacodyl 10 mg PR QHS:PRN constipation 10. Senna 8.6 mg PO BID:PRN constipation 11. Fleet Enema ___AILY:PRN constipation 12. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Jevity 50cc per hour run until 1200 cc infused Check for residual every 6 hours. If 100 cc or over hold tube feeds for 1 hour. Elevated HOB 45 degrees during feeding and one hour after. Change Y connector q 24 hours and cleanse site normal site Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever or pain 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 5. Carbidopa-Levodopa (___) 1 TAB PO TID 6. Clopidogrel 75 mg PO DAILY 7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Senna 8.6 mg PO BID:PRN constipation 10. Fleet Enema ___AILY:PRN constipation 11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 12. Atorvastatin 80 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Aspiration Pneumonia ___ Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were brought to the hospital after an episode of aspiration and shortness of breath. Your x-ray showed concerns for a pneumonia. You were treated with antiobitics. You breathing appeared comfortable throughout your admission here. You will remain on antibiotics for a total of 7 days (last day ___. Followup Instructions: ___
[ "J690", "E43", "G20", "I69391", "Z931", "Z681", "I10", "E785", "R1310" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: shortness of breath and choking Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] male with [MASKED], history of left hemispheric stroke, hypertension, and hyperlipidemia with recent admission for pneumonia and multifocal CVA presents from rehab with a change in mental status, seating and coudhing with audible crackles shortness of breath. History limited but his dtr reports that she was with the pt when she tried to remove a solid piece of ?food from his mouth with her finger wrapped in a paper napkin. After doing this she noted him to have some respiratory distress and noted him to "be choking" and needing suction. She reports the staff at the rehab stated they could not suction him without a doctors [MASKED]. Has been wearing o2 at baseline, 2L the patient had an episode of vomiting this evening at rehab followed by difficulty breathing and hypoxia. He received neb treatments with some improvement but they are unable to suction him at rehab so the daughter requested transfer to the ED . In ER: (Triage Vitals: unable |96.1 |86 |128/73 |20 |96% Nasal Cannula ) Meds Given: [MASKED] 00:39 IV Vancomycin 1000 mg Fluids given: None Radiology Studies: None consults called. None . PAIN SCALE: [MASKED] per patient He did report to her a few days ago shortness of breath. She has noticed however that during the course of his rehab his breathing has improved. He was last home in [MASKED] and walked to his appointments in [MASKED]. All other limited ROS negative as above. Past Medical History: - Pneumonitis due to inhalation of food and vomit - Metabolic encephalopathy - [MASKED] disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory [MASKED] - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids - Essential HTN Dysphagia following CVA Generalized muscle weakness Gastrostomy status Social History: [MASKED] Family History: Per his dtr his parents died of natural causes. She cannot tell me how old they were when they died. Physical Exam: ADMISSION EXAM: Vitals: T 98.3 P 95 BP 115/68 RR 18 SaO2 96% 2L CONS: Thin, elderly gentleman NAD, contracted, + temporal wasting HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: Crackles at the bases b/l GI: G tube site, C/D/I, no rebound or guarding GU: normal genetalia MSK:no c/c/e 2+pulses SKIN: stage II decubitus NEURO: contracted b/l upper extremities, he does not appear to respond to voice, He tries to swat our hands away when we turn him PSYCH: calm, cooperative LAD: No cervical LAD DISCHARGE EXAM: Vital Signs: 98.5 138/57 70 24 92%RA GEN: Alert, opens eyes to voice but does not answer questions, pushing me away when I attempt to examine him HEENT: NC/AT, masked facies CV: RRR, no m/r/g PULM: CTA on anterior auscultation, somewhat limited exam as patient keeps pushing me away GI: soft, BS present, no apparent tenderness, G-tube present EXT: no [MASKED] edema noted NEURO: Notable rigidity throughout, otherwise largely not cooperative with exam (does continue to push me away with left hand) Pertinent Results: Admission Labs: [MASKED] 08:50PM BLOOD WBC-11.8*# RBC-3.14* Hgb-9.7* Hct-31.4* MCV-100* MCH-30.9 MCHC-30.9* RDW-16.0* RDWSD-58.4* Plt [MASKED] [MASKED] 08:50PM BLOOD Neuts-80.1* Lymphs-10.9* Monos-6.7 Eos-1.5 Baso-0.3 Im [MASKED] AbsNeut-9.42* AbsLymp-1.28 AbsMono-0.79 AbsEos-0.18 AbsBaso-0.04 [MASKED] 08:50PM BLOOD Glucose-116* UreaN-36* Creat-0.8 Na-141 K-6.8* Cl-108 HCO3-22 AnGap-18 [MASKED] 08:50PM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9 Discharge Labs: [MASKED] 06:10AM BLOOD WBC-6.3 RBC-2.90* Hgb-9.0* Hct-28.6* MCV-99* MCH-31.0 MCHC-31.5* RDW-15.4 RDWSD-56.0* Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-127* UreaN-30* Creat-0.8 Na-142 K-4.3 Cl-108 HCO3-26 AnGap-12 [MASKED] 06:10AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2 Other Labs: [MASKED] 08:50PM BLOOD proBNP-457 [MASKED] 08:57PM BLOOD Lactate-1.4 K-6.0* Blood Cx x [MASKED] - [MASKED] 8:50 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [MASKED], [MASKED] @ 23:54 ([MASKED]). Blood Cx x 3 PENDING, w/ NGTD URINE Legionella Antigen NEGATIVE MRSA Screen negative ECG - Sinus rhythm. Baseline artifact. Increase in rate as compared with prior ECG [MASKED]. Low limb lead voltage. Compared to the previous tracing no diagnostic interim change. CXR - FINDINGS: AP upright and lateral views of the chest provided. There is new consolidation in the left mid to upper lung which is concerning for pneumonia. Coarsened markings in the lower lungs may reflect sequelae of chronic aspiration. Right upper lobe appears partially collapsed. Cardiomediastinal silhouette is unchanged. IMPRESSION: Findings concerning for new pneumonia in the left mid lung. Brief Hospital Course: [MASKED] y/o M with PMHx of HTN, HLD, prior CVA in [MASKED], [MASKED], recurrent aspiration, who presented from rehab with cough, shortness of breath, confusion. This occurred ? after an episode of emesis. In the ED, imaging was concerning for PNA. He was admitted for tx of PNA. # Aspiration PNA: Breathing comfortably. Lungs clear on anterior auscultation. Given seemingly sudden-onset of respiratory distress followed by rapid improvement, this raises the question of whether patient has true aspiration PNA vs. aspiration pneumonitis. She was initially treated with broad regimen of vanc / cefepime / levofloxacin. Given rapid clinical improvement, abx were narrowed to Augmentin monotherapy, and pt remains stable on this regimen. Plan is to continue for a total 7 day course of abx for aspiration PNA (last day [MASKED]. # + Blood Cx: Suspect contaminant. 1 blood cx with CONS, no other positive blood cx. # [MASKED] Disease: On home carbidopa/levodopa. # HLD: On home statin. # Prior CVA: On ASA/Plavix. # Severe Malnutrition: On tube feeds, nutrition c/s following. TRANSITIONAL ISSUES: - Continue Augmentin regimen until [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 5. Atorvastatin 80 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Acetaminophen 650 mg PO Q6H:PRN fever or pain 8. Aspirin 81 mg PO DAILY 9. Bisacodyl 10 mg PR QHS:PRN constipation 10. Senna 8.6 mg PO BID:PRN constipation 11. Fleet Enema AILY:PRN constipation 12. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Jevity 50cc per hour run until 1200 cc infused Check for residual every 6 hours. If 100 cc or over hold tube feeds for 1 hour. Elevated HOB 45 degrees during feeding and one hour after. Change Y connector q 24 hours and cleanse site normal site Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever or pain 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 5. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 6. Clopidogrel 75 mg PO DAILY 7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Senna 8.6 mg PO BID:PRN constipation 10. Fleet Enema AILY:PRN constipation 11. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 12. Atorvastatin 80 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Aspiration Pneumonia [MASKED] Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were brought to the hospital after an episode of aspiration and shortness of breath. Your x-ray showed concerns for a pneumonia. You were treated with antiobitics. You breathing appeared comfortable throughout your admission here. You will remain on antibiotics for a total of 7 days (last day [MASKED]. Followup Instructions: [MASKED]
[]
[ "I10", "E785" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "E43: Unspecified severe protein-calorie malnutrition", "G20: Parkinson's disease", "I69391: Dysphagia following cerebral infarction", "Z931: Gastrostomy status", "Z681: Body mass index [BMI] 19.9 or less, adult", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "R1310: Dysphagia, unspecified" ]
10,050,755
26,698,047
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: altered mental status, right arm weakness Major Surgical or Invasive Procedure: ___ PEG placement by ___ History of Present Illness: The patient is an ___ year-old ___ speaking man with a history of ___ disease, left hemisphere ischemic strokes ___, HTN and HLD who presents to the ED with worsening mental status and right arm weakness. FROM NEUROLOGY NOTE AND DAUGHTER Per the patient's daughter, Mr. ___ has been unwell since for the last two weeks and was seen by his PCP and started on Levaquin for community acquired pneumonia. He became more confused and agitated at home and speaking barely any words (not far from his baseline of a man of few words). His family found it difficult to care from him at home and he was barely able to make transfers with 2 person assist. He was not eating well, but somehow family was able to coax him to take his meds. Yesterday, while cleaning the patient and attempting to bathe him they noticed he was not moving his right arm. His daughter is not exactly sure if this came on suddenly or gradually with the onset of the pneumonia. In the ED, initial vital signs were: 98.3 80 137/47 16 96% RA - Exam was notable for: - Labs were notable for: white cell count of 14.8, lactate of 2.5, creatinine of 1.6 and negative tox screen. - Imaging: CT HEAD: Extensive chronic microvascular ischemic disease and chronic infarcts. There is no intracranial hemorrhage. Loss of gray-white differentiation in the superior left precentral gyrus seen on a single slice (02:30) may artifactual or represent acute ischemia. MRI is more sensitive for detection of an acute ischemic event if there is high clinical suspicion. There is an air-fluid level in the right maxillary sinus CT NECK:The left vertebral artery is dominant. There is moderate calcified and noncalcified plaque in the left carotid bulb and proximal left internal carotid artery. There is no evidence of dissection, occlusion, or flow limiting stenosis involving the internal carotid and vertebral arteries. Extensive cavernous carotid calcifications are present. Tributaries of circle ___ are patent. There is no large aneurysm. CXR:Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. - The patient was given: ___ 19:04 IVF 1000 mL NS 1000 mL ___ ___ 20:48 IV CeftriaXONE 1 gm ___ ___ 21:43 IV Azithromycin 500 mg ___ ___ 21:44 IVF 1000 mL NS ___ Started 75 mL/hr ___ 21:59 PR Aspirin 600 mg An NG tube was placed as the patient was so somnolent and altered. - Consults: Neurology recommended urgent MRI brain Upon arrival to the floor, patient is somnolent but groans when spoken to. Past Medical History: - ___ disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory ___ - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids Social History: ___ Family History: Per his daughter, no family history of strokes/seizures. Physical Exam: ADMISSION EXAM: VITALS: 98.1 138 / 43 61 18 96 GENERAL: Somnolent, and wakes up to name, otherwise not responding to any questions HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Bilateral rhonchi at bases ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. NEUROLOGIC: Not co-operative with neuro exam. Left upper extremity with increased tone compared to right. Withdraws to pain in all four extremities. Normal biceps/triceps/knee jerk reflexes DISCHARGE EXAM: Objective: Tmax 99.6 112-140/ 44-57 68 24 100% 1.5L. General: Opens right eye to command, moves extremities with stimulation. Non-verbal, mildly tachypenic, no cyanosis. Increased respiratory muscle use in the neck accessory. HEENT: NC/AT. No scleral icterus, conjunctival pallor Cardiac: RRR, S1, S2. No extra sounds Lungs: diffuse wheezes and crackles b/l Abdomen: Soft. NTND Extremities: Warm, well perfused, no cyanosis. Emaciated. Neurologic: Difficult to assess. Rigid, L > R. Contracted. Withdraws to pain and grossly moves all extremities. Pertinent Results: ADMISSION LABS: ___ 05:10PM BLOOD WBC-14.7*# RBC-3.60* Hgb-11.2* Hct-35.4* MCV-98 MCH-31.1 MCHC-31.6*# RDW-13.2 RDWSD-46.4* Plt ___ ___ 05:10PM BLOOD Neuts-86.4* Lymphs-7.1* Monos-5.2 Eos-0.5* Baso-0.3 Im ___ AbsNeut-12.97* AbsLymp-1.07* AbsMono-0.78 AbsEos-0.07 AbsBaso-0.04 ___ 05:10PM BLOOD ___ PTT-27.3 ___ ___ 05:10PM BLOOD Glucose-127* UreaN-62* Creat-1.6* Na-147* K-3.7 Cl-109* HCO3-26 AnGap-16 ___ 05:10PM BLOOD ALT-7 AST-30 AlkPhos-87 TotBili-0.6 ___ 05:10PM BLOOD Lipase-49 ___ 05:10PM BLOOD Albumin-3.2* ___ 02:51AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-1.9 ___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:30PM BLOOD Lactate-2.5* ___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 09:00PM URINE RBC-60* WBC-17* Bacteri-FEW Yeast-NONE Epi-0 ___ 02:51AM URINE Hours-RANDOM UreaN-1139 Creat-83 Na-82 K-46 Cl-84 ___ 02:51AM URINE Osmolal-806 ___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS: ___ 05:55AM BLOOD calTIBC-114* Hapto-257* Ferritn-840* TRF-88* ___ 05:22AM BLOOD Triglyc-77 ___ 05:28AM BLOOD TSH-1.2 DISCHARGE LABS: MICROBIOLOGY: ___ BLOOD CULTURE X2: NO GROWTH (FINAL) ___ URINE CULTURE: NO GROWTH (FINAL) ___ BLOOD CULTURE X2: NO GROWTH (FINAL) STUDIES: ___ CXR: IMPRESSION: Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. ___ CTA HEAD & NECK: 1. Patent circle of ___. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. New area of hypoattenuation in the left precentral gyrus, which may represent a chronic infarction. Unchanged chronic infarctions in the bilateral occipital, left frontal, and left parietal lobes with probable sequela of severe chronic small vessel ischemic disease. MRI may be obtained for further evaluation. 4. Paranasal sinus disease. 5. Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. These guidelines are based upon ___ criteria. ___ BRAIN MRI: 1. Please note the study is substantially degraded by motion. 2. Multiple small acute infarctions in the left MCA and PCA territory. No definite associated hemorrhage, although markedly limited in evaluation given motion artifact. 3. Confluent background of white matter signal abnormality, likely secondary to extensive chronic microvascular ischemic changes. ___ Imaging CHEST (PORTABLE AP) : Cardiomediastinal silhouette is within normal limits. There is again seen an area of consolidation within the right upper lobe which appears more confluent. Additional opacities at the lung bases are unchanged. No pneumothoraces are seen. ___ Imaging CHEST (PORTABLE AP) Heart size and mediastinum are unchanged. There is interval progression of multifocal consolidations in the right lung, substantial as well as unchanged or minimally worse appearance of the left middle lower lung consolidations. The findings are concerning for multifocal infection. >> DISCHARGE LABS: ___ 05:56AM BLOOD WBC-5.9 RBC-2.61* Hgb-8.0* Hct-25.7* MCV-99* MCH-30.7 MCHC-31.1* RDW-15.0 RDWSD-53.3* Plt ___ ___ 06:36AM BLOOD ___ ___ 05:56AM BLOOD Glucose-130* UreaN-28* Creat-0.8 Na-137 K-4.9 Cl-106 HCO3-24 AnGap-12 . >> MICROBIOLOGY ; __________________________________________________________ ___ 4:43 am URINE Source: ___. URINE CULTURE (Pending): __________________________________________________________ ___ 12:20 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 9:31 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:49 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 3:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 9:18 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ ___ ON ___ @ 13:40. GRAM POSITIVE COCCI IN CLUSTERS. Brief Hospital Course: Mr. ___ is an ___ year-old ___ speaking man with a history of ___ disease, left hemisphere ischemic strokes ___, HTN and HLD who presented to the ED with worsening mental status and right arm weakness in the setting of a persistent pneumonia. . >> ACTIVE ISSUES: # Acute Encephalopathy: Patient initially was hospitalized for right sided weakness and worsening mental status. Patient was found to be minimally verbal, and likely thought to have multifactorial etiology for symptoms, including multifocal pneumonia, multifocal CVA seen on brain MRI on ___, and also hypernatremia. Furthermore, patient has underlying ___ disease. Patient required initially mits and these were then discontinued and patient had likely new baseline mental status after treatment for the above. Patient was treated for a second pneumonia, and patient's mental status was minimally verbal, favoring his left side, and intermittent tracking. . # Multifocal Cerbrovascular Event: Patient initially was found to have right sided weakness, and imaging revealed a multifocal CVA in MCA/PCA watershed distribution similar to prior. He continued to receive aspirin, Plavix and atorvastatin with plan for 3 months per neurology stroke. Patient's outpatient neurologist was contacted, and likely has had prior CVAs and likely is responsible for patient's Parkinsons. Patient then . # Pneumonia. Patient initially presented with community acquired pneumonia after failing outpatient levofloxacin treatment. Patient s/p treatment with ceftriaxone and azithromycin for CAP. However, during hospitalization and mental status, patient continued to have aspiration. Patient had an aspiration event leading to an acute hypoxia on ___, and patient then developed a fever in ___. Patient then started on vancomycin and cefepime for completion of true HCAP course. Patient finished IV antibiotics on ___, and then to continue augmentin x 3 days for continued aspiriation coverage. It was discussed with patient's family several times during hospital stay, that likely G-tube is not a prevention for an aspiration type event, and there is a high likelihood for recurrent aspiration in the future. . # Severe Malnutrition: Patient intermittently received peripheral parenteral nutrition x 4 days prior to Dobhoff being placed on ___. Patient had previously had enteral access attempts, and finally PEG tube placed on ___. Patient has been getting tube feeds, and has been followed by nutrition closely. It was discussed repeatedly that aspiration events are not prevented with G-tube placement. Patient was tolerating tube feeds well. . # Anemia: Normocytic, iron studies concerning for anemia of chronic disease. Hemoglobin was trended during hospital stay without obvious signs of bleeding. . # Acute Kidney Injury: patient's creatinine was trended during hospital stay and remained at baseline. . # ___ Disease: Patient is currently on sinemet, this was originally changed to dissolvable carbidopa-levodopa, and Effexor and zonisamide for tremor were discontinued given non enteral access and uncertain benefit. Patient's neurologist was contacted, Dr. ___ discussion regarding potential prognosis given underlying ___ Disease with no worsening status. Patient was restarted on sinemet through G-tube without difficulty. Neurologic exam as above. . #HTN: Lisinopril was held and not restarted, as it was not necessary. . #HLD: Atorvastatin changed to 80 mg qd given new stroke. . TRANSITIONAL ISSUES: # Aspiration Pneumonia: Patient now finishing course of Vancomycin / Cefepime /Flagyl, and transitioned to Augmentin x 3 days for continued treatment until ___. Would consider repeat chest imaging as an outpatient in ___ weeks pending clinical status for resolution # G-tube: Patient's G-tube functioning properly, patient to be contacted by Interventional radiology department regarding further maintenance and changing of tube # Dyspnea: Discussed with family that patient would most likely benefit from low dose morphine for apparent dyspnea, to be further considered as outpatient. # Pulmonary Nodules: Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. # Stroke: Patient to be continued on Plavix 75 mg/atorva 80 mg until at least ___ # Aspiration: Patient remains NPO on aspiration precautions. # ___ Disease: Patient to be continued on sinemet as outpatient, with f/u with Dr. ___ # Goals of Care: It was discussed several times likelihood for recovery back to baseline quite low, please continue to readdress as outpatient. Patient remains full code. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 10 mg PO QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Creon 12 1 CAP PO TID W/MEALS 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 6. Lisinopril 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY 9. Zonisamide 100 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24 hour transdermal daily 12. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 80 mg NG QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Clopidogrel 75 mg NG DAILY 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea/wheeze 7. Bisacodyl 10 mg PR QHS:PRN constipation 8. Aspirin 81 mg NG DAILY 9. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 3 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ischemic Cerebrovascular Accident 2. Multifocal Pneumonia 3. Hypernatremia 4. Acute Kidney Injury SECONDARY DIAGNOSES: ___ Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted for a change in your mental status and difficulty moving your right arm. You were found to have had another stroke similar to your previous stroke. This is the cause of your right arm weakness. We have added a new medication called clopidogrel and increased the dose of your atorvastatin, in an attempt to reduce your risk of another stroke. You were found to have a pneumonia as well and we treated you with intravenous antibiotics. Your sodium was also high so we gave you intravenous fluids to improve this. You were unable to eat on your own, so we had to give you a feeding tube through which you will continue to receive nutrition. While here, you likely developed a recurrent pneumonia likely from aspiration, and finished antibiotics for this as well. Please continue to take your home medications as prescribed. We wish you the best, Your ___ team Followup Instructions: ___
[ "I63132", "J189", "J690", "E43", "N179", "G92", "E870", "G8191", "R1310", "G20", "R4701", "I10", "D638", "F0280", "E785", "H9193", "E860", "Z6820", "R918", "R197", "H409", "Z781", "R0902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: altered mental status, right arm weakness Major Surgical or Invasive Procedure: [MASKED] PEG placement by [MASKED] History of Present Illness: The patient is an [MASKED] year-old [MASKED] speaking man with a history of [MASKED] disease, left hemisphere ischemic strokes [MASKED], HTN and HLD who presents to the ED with worsening mental status and right arm weakness. FROM NEUROLOGY NOTE AND DAUGHTER Per the patient's daughter, Mr. [MASKED] has been unwell since for the last two weeks and was seen by his PCP and started on Levaquin for community acquired pneumonia. He became more confused and agitated at home and speaking barely any words (not far from his baseline of a man of few words). His family found it difficult to care from him at home and he was barely able to make transfers with 2 person assist. He was not eating well, but somehow family was able to coax him to take his meds. Yesterday, while cleaning the patient and attempting to bathe him they noticed he was not moving his right arm. His daughter is not exactly sure if this came on suddenly or gradually with the onset of the pneumonia. In the ED, initial vital signs were: 98.3 80 137/47 16 96% RA - Exam was notable for: - Labs were notable for: white cell count of 14.8, lactate of 2.5, creatinine of 1.6 and negative tox screen. - Imaging: CT HEAD: Extensive chronic microvascular ischemic disease and chronic infarcts. There is no intracranial hemorrhage. Loss of gray-white differentiation in the superior left precentral gyrus seen on a single slice (02:30) may artifactual or represent acute ischemia. MRI is more sensitive for detection of an acute ischemic event if there is high clinical suspicion. There is an air-fluid level in the right maxillary sinus CT NECK:The left vertebral artery is dominant. There is moderate calcified and noncalcified plaque in the left carotid bulb and proximal left internal carotid artery. There is no evidence of dissection, occlusion, or flow limiting stenosis involving the internal carotid and vertebral arteries. Extensive cavernous carotid calcifications are present. Tributaries of circle [MASKED] are patent. There is no large aneurysm. CXR:Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. - The patient was given: [MASKED] 19:04 IVF 1000 mL NS 1000 mL [MASKED] [MASKED] 20:48 IV CeftriaXONE 1 gm [MASKED] [MASKED] 21:43 IV Azithromycin 500 mg [MASKED] [MASKED] 21:44 IVF 1000 mL NS [MASKED] Started 75 mL/hr [MASKED] 21:59 PR Aspirin 600 mg An NG tube was placed as the patient was so somnolent and altered. - Consults: Neurology recommended urgent MRI brain Upon arrival to the floor, patient is somnolent but groans when spoken to. Past Medical History: - [MASKED] disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory [MASKED] - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids Social History: [MASKED] Family History: Per his daughter, no family history of strokes/seizures. Physical Exam: ADMISSION EXAM: VITALS: 98.1 138 / 43 61 18 96 GENERAL: Somnolent, and wakes up to name, otherwise not responding to any questions HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Bilateral rhonchi at bases ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. NEUROLOGIC: Not co-operative with neuro exam. Left upper extremity with increased tone compared to right. Withdraws to pain in all four extremities. Normal biceps/triceps/knee jerk reflexes DISCHARGE EXAM: Objective: Tmax 99.6 112-140/ 44-57 68 24 100% 1.5L. General: Opens right eye to command, moves extremities with stimulation. Non-verbal, mildly tachypenic, no cyanosis. Increased respiratory muscle use in the neck accessory. HEENT: NC/AT. No scleral icterus, conjunctival pallor Cardiac: RRR, S1, S2. No extra sounds Lungs: diffuse wheezes and crackles b/l Abdomen: Soft. NTND Extremities: Warm, well perfused, no cyanosis. Emaciated. Neurologic: Difficult to assess. Rigid, L > R. Contracted. Withdraws to pain and grossly moves all extremities. Pertinent Results: ADMISSION LABS: [MASKED] 05:10PM BLOOD WBC-14.7*# RBC-3.60* Hgb-11.2* Hct-35.4* MCV-98 MCH-31.1 MCHC-31.6*# RDW-13.2 RDWSD-46.4* Plt [MASKED] [MASKED] 05:10PM BLOOD Neuts-86.4* Lymphs-7.1* Monos-5.2 Eos-0.5* Baso-0.3 Im [MASKED] AbsNeut-12.97* AbsLymp-1.07* AbsMono-0.78 AbsEos-0.07 AbsBaso-0.04 [MASKED] 05:10PM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 05:10PM BLOOD Glucose-127* UreaN-62* Creat-1.6* Na-147* K-3.7 Cl-109* HCO3-26 AnGap-16 [MASKED] 05:10PM BLOOD ALT-7 AST-30 AlkPhos-87 TotBili-0.6 [MASKED] 05:10PM BLOOD Lipase-49 [MASKED] 05:10PM BLOOD Albumin-3.2* [MASKED] 02:51AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-1.9 [MASKED] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 05:30PM BLOOD Lactate-2.5* [MASKED] 09:00PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD [MASKED] 09:00PM URINE RBC-60* WBC-17* Bacteri-FEW Yeast-NONE Epi-0 [MASKED] 02:51AM URINE Hours-RANDOM UreaN-1139 Creat-83 Na-82 K-46 Cl-84 [MASKED] 02:51AM URINE Osmolal-806 [MASKED] 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS: [MASKED] 05:55AM BLOOD calTIBC-114* Hapto-257* Ferritn-840* TRF-88* [MASKED] 05:22AM BLOOD Triglyc-77 [MASKED] 05:28AM BLOOD TSH-1.2 DISCHARGE LABS: MICROBIOLOGY: [MASKED] BLOOD CULTURE X2: NO GROWTH (FINAL) [MASKED] URINE CULTURE: NO GROWTH (FINAL) [MASKED] BLOOD CULTURE X2: NO GROWTH (FINAL) STUDIES: [MASKED] CXR: IMPRESSION: Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. [MASKED] CTA HEAD & NECK: 1. Patent circle of [MASKED]. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. New area of hypoattenuation in the left precentral gyrus, which may represent a chronic infarction. Unchanged chronic infarctions in the bilateral occipital, left frontal, and left parietal lobes with probable sequela of severe chronic small vessel ischemic disease. MRI may be obtained for further evaluation. 4. Paranasal sinus disease. 5. Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. These guidelines are based upon [MASKED] criteria. [MASKED] BRAIN MRI: 1. Please note the study is substantially degraded by motion. 2. Multiple small acute infarctions in the left MCA and PCA territory. No definite associated hemorrhage, although markedly limited in evaluation given motion artifact. 3. Confluent background of white matter signal abnormality, likely secondary to extensive chronic microvascular ischemic changes. [MASKED] Imaging CHEST (PORTABLE AP) : Cardiomediastinal silhouette is within normal limits. There is again seen an area of consolidation within the right upper lobe which appears more confluent. Additional opacities at the lung bases are unchanged. No pneumothoraces are seen. [MASKED] Imaging CHEST (PORTABLE AP) Heart size and mediastinum are unchanged. There is interval progression of multifocal consolidations in the right lung, substantial as well as unchanged or minimally worse appearance of the left middle lower lung consolidations. The findings are concerning for multifocal infection. >> DISCHARGE LABS: [MASKED] 05:56AM BLOOD WBC-5.9 RBC-2.61* Hgb-8.0* Hct-25.7* MCV-99* MCH-30.7 MCHC-31.1* RDW-15.0 RDWSD-53.3* Plt [MASKED] [MASKED] 06:36AM BLOOD [MASKED] [MASKED] 05:56AM BLOOD Glucose-130* UreaN-28* Creat-0.8 Na-137 K-4.9 Cl-106 HCO3-24 AnGap-12 . >> MICROBIOLOGY ; [MASKED] [MASKED] 4:43 am URINE Source: [MASKED]. URINE CULTURE (Pending): [MASKED] [MASKED] 12:20 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] [MASKED] 9:31 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 5:49 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 3:45 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 9:18 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] ON [MASKED] @ 13:40. GRAM POSITIVE COCCI IN CLUSTERS. Brief Hospital Course: Mr. [MASKED] is an [MASKED] year-old [MASKED] speaking man with a history of [MASKED] disease, left hemisphere ischemic strokes [MASKED], HTN and HLD who presented to the ED with worsening mental status and right arm weakness in the setting of a persistent pneumonia. . >> ACTIVE ISSUES: # Acute Encephalopathy: Patient initially was hospitalized for right sided weakness and worsening mental status. Patient was found to be minimally verbal, and likely thought to have multifactorial etiology for symptoms, including multifocal pneumonia, multifocal CVA seen on brain MRI on [MASKED], and also hypernatremia. Furthermore, patient has underlying [MASKED] disease. Patient required initially mits and these were then discontinued and patient had likely new baseline mental status after treatment for the above. Patient was treated for a second pneumonia, and patient's mental status was minimally verbal, favoring his left side, and intermittent tracking. . # Multifocal Cerbrovascular Event: Patient initially was found to have right sided weakness, and imaging revealed a multifocal CVA in MCA/PCA watershed distribution similar to prior. He continued to receive aspirin, Plavix and atorvastatin with plan for 3 months per neurology stroke. Patient's outpatient neurologist was contacted, and likely has had prior CVAs and likely is responsible for patient's Parkinsons. Patient then . # Pneumonia. Patient initially presented with community acquired pneumonia after failing outpatient levofloxacin treatment. Patient s/p treatment with ceftriaxone and azithromycin for CAP. However, during hospitalization and mental status, patient continued to have aspiration. Patient had an aspiration event leading to an acute hypoxia on [MASKED], and patient then developed a fever in [MASKED]. Patient then started on vancomycin and cefepime for completion of true HCAP course. Patient finished IV antibiotics on [MASKED], and then to continue augmentin x 3 days for continued aspiriation coverage. It was discussed with patient's family several times during hospital stay, that likely G-tube is not a prevention for an aspiration type event, and there is a high likelihood for recurrent aspiration in the future. . # Severe Malnutrition: Patient intermittently received peripheral parenteral nutrition x 4 days prior to Dobhoff being placed on [MASKED]. Patient had previously had enteral access attempts, and finally PEG tube placed on [MASKED]. Patient has been getting tube feeds, and has been followed by nutrition closely. It was discussed repeatedly that aspiration events are not prevented with G-tube placement. Patient was tolerating tube feeds well. . # Anemia: Normocytic, iron studies concerning for anemia of chronic disease. Hemoglobin was trended during hospital stay without obvious signs of bleeding. . # Acute Kidney Injury: patient's creatinine was trended during hospital stay and remained at baseline. . # [MASKED] Disease: Patient is currently on sinemet, this was originally changed to dissolvable carbidopa-levodopa, and Effexor and zonisamide for tremor were discontinued given non enteral access and uncertain benefit. Patient's neurologist was contacted, Dr. [MASKED] discussion regarding potential prognosis given underlying [MASKED] Disease with no worsening status. Patient was restarted on sinemet through G-tube without difficulty. Neurologic exam as above. . #HTN: Lisinopril was held and not restarted, as it was not necessary. . #HLD: Atorvastatin changed to 80 mg qd given new stroke. . TRANSITIONAL ISSUES: # Aspiration Pneumonia: Patient now finishing course of Vancomycin / Cefepime /Flagyl, and transitioned to Augmentin x 3 days for continued treatment until [MASKED]. Would consider repeat chest imaging as an outpatient in [MASKED] weeks pending clinical status for resolution # G-tube: Patient's G-tube functioning properly, patient to be contacted by Interventional radiology department regarding further maintenance and changing of tube # Dyspnea: Discussed with family that patient would most likely benefit from low dose morphine for apparent dyspnea, to be further considered as outpatient. # Pulmonary Nodules: Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. # Stroke: Patient to be continued on Plavix 75 mg/atorva 80 mg until at least [MASKED] # Aspiration: Patient remains NPO on aspiration precautions. # [MASKED] Disease: Patient to be continued on sinemet as outpatient, with f/u with Dr. [MASKED] # Goals of Care: It was discussed several times likelihood for recovery back to baseline quite low, please continue to readdress as outpatient. Patient remains full code. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 10 mg PO QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 4. Creon 12 1 CAP PO TID W/MEALS 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 6. Lisinopril 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY 9. Zonisamide 100 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24 hour transdermal daily 12. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 80 mg NG QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Clopidogrel 75 mg NG DAILY 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea/wheeze 7. Bisacodyl 10 mg PR QHS:PRN constipation 8. Aspirin 81 mg NG DAILY 9. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 3 Days Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ischemic Cerebrovascular Accident 2. Multifocal Pneumonia 3. Hypernatremia 4. Acute Kidney Injury SECONDARY DIAGNOSES: [MASKED] Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr [MASKED], It was a pleasure taking care of you during your hospital stay at [MASKED]. You were admitted for a change in your mental status and difficulty moving your right arm. You were found to have had another stroke similar to your previous stroke. This is the cause of your right arm weakness. We have added a new medication called clopidogrel and increased the dose of your atorvastatin, in an attempt to reduce your risk of another stroke. You were found to have a pneumonia as well and we treated you with intravenous antibiotics. Your sodium was also high so we gave you intravenous fluids to improve this. You were unable to eat on your own, so we had to give you a feeding tube through which you will continue to receive nutrition. While here, you likely developed a recurrent pneumonia likely from aspiration, and finished antibiotics for this as well. Please continue to take your home medications as prescribed. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "I10", "E785" ]
[ "I63132: Cerebral infarction due to embolism of left carotid artery", "J189: Pneumonia, unspecified organism", "J690: Pneumonitis due to inhalation of food and vomit", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "G92: Toxic encephalopathy", "E870: Hyperosmolality and hypernatremia", "G8191: Hemiplegia, unspecified affecting right dominant side", "R1310: Dysphagia, unspecified", "G20: Parkinson's disease", "R4701: Aphasia", "I10: Essential (primary) hypertension", "D638: Anemia in other chronic diseases classified elsewhere", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "E785: Hyperlipidemia, unspecified", "H9193: Unspecified hearing loss, bilateral", "E860: Dehydration", "Z6820: Body mass index [BMI] 20.0-20.9, adult", "R918: Other nonspecific abnormal finding of lung field", "R197: Diarrhea, unspecified", "H409: Unspecified glaucoma", "Z781: Physical restraint status", "R0902: Hypoxemia" ]
10,050,823
20,436,894
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I've been hearing voices." Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with history of MDD, GAD, panic disorder with agoraphobia and alcohol use disorder who self-presented with worsening depression, auditory hallucinations in the setting of numerous psychosocial stressors. . On interview, patient expressed that she has been hearing a voice since last night. She explained that she had not heard this voice in ___ years (since she hospitalized at ___). When asked about recent stressors, she replied, "the usual, school and work." She explained that she attends ___ (studying psychology/juvenile crime) and nannies. She denied depressed mood, hopelessness, anhedonia but endorsed increased sleep (12 h/24h period), low energy/motivation, increased appetite and 'so so' focus (longstanding). She denied SI/HI. . She explained that ___ years ago, the voice initially would just keep her company and would laugh with her. However, since last night, when the voice came back, she expressed that it has been screaming and screaming her name. She expressed she does not recognize the voice but expressed it sounds kind of like her dad's voice but deeper. She denied any other content of the voice outside of wordless screaming and her name. She denied CAH, VH, IOR, TC/TB/TI, paranoid ideation. She denied periods of decreased need for sleep with concurrent distractibility, elevated/irritable mood, grandiosity, racing thoughts, increased goal directed/risky behavior and/or pressured speech. . Patient endorsed 'terrible' anxiety. She expressed that she does not like to leave the house and that this fear of leaving the house has gotten worse over the past few months. She endorsed a fear of something happening while she is on the train that would lead to a crash and her death. She denied any related experience with similar situations. She also endorsed anxiety relating to school, big crowds, unfamiliar people as well as excessive worrying about school and finances to the point that it at times interferes with her daily functioning. . Patient explained that ___ years ago she was hospitalized at ___ while in high school because she was 'super depressed' and heard the aforementioned voice. She expressed that at the time they said she was 'so depressed' that she began to hear voices and started her on Effexor. On follow, patient again denied SI/HI, ___ and expressed a willingness to reach out to mother, outpatient providers, call ___, BEST and return to the ED should she begin to feel unsafe after discharge. She was amenable with scheduling an earlier appointment with Dr. ___ at ___ and to scheduling an intake at an ___ PHP. . Collateral: ___ (mother) ___: increasing anxiety and depression c this semester, but no concerns relating to safety. Mother denied any safety concerns and felt as though patient was a reliable reporter of safety. Past Medical History: PAST PSYCHIATRIC HISTORY: Diagnosis: ?MDD c psychotic features; per patient, depression and anxiety, alcohol use d/o; per ___, MDD, moderate, recurrent, GAD, panic d/o Hospitalizations: ___ ___ for ___, ___ ___ for ?AH, PHP at ___ before hospitalization Current treaters and treatment: Dr. ___ at ___, no therapist Medication and ECT trials: Effexor (lost weight, withdrawal symptoms if missed dose), Citalopram (works well), Lorazepam (works well), Propranol (works well), Escitalopram (at ___ yo, does not remember), Sertraline (stomach aches), Duloxetine and Gabapentin Self-injury: hit head and tried to OD (Oxy/alcohol) at ___ yo (did not go to hospital), at ___ yo tried to drink self to death (passed out, did not go to hospital), also h/o cutting since ___ yo and headbanging since ___ yo Harm to others: denied Access to weapons: denied PAST MEDICAL HISTORY: PCP: new PCP at ___ (has not yet seen, does not remember name) ___ Social History: ___ Family History: FAMILY PSYCHIATRIC HISTORY: Brother-?bipolar ___ uncle-?bipolar Physical ___: =========================== ADMISSION PHYSICAL EXAM =========================== *VS: BP: 140/90 HR: 103 temp: 99.8 resp: 19 O2 sat: 100 Neurological: *station and gait: normal/normal *tone and strength: normal/intact abnormal movements: none appreciated Cognition: Wakefulness/alertness: awake, alert *Attention (MOYB): ___ *Orientation: oriented to person, place, time/date *Memory: Reg ___ Recall ___ at 5 min *Fund of knowledge: ___ recent US presidents Calculations: 2.25=9q Abstraction: apple/orange=fruit *Speech: normal tone, volume, rate, slightly flattened prosody *Language: fluent, normal comprehension Mental Status: *Appearance: appears reported age, dressed in hospital attire, adequate grooming/hygiene Behavior: cooperative, relatively well related, appropriate eye contact *Mood and Affect: 'all right'/somewhat incongruent given tearfulness at times and anxious appearance but otherwise reactive appropriately during interview *Thought process / *associations: linear, coherent/no LOA *Thought Content: denied SI, HI, VH, CAH, endorsed AH but did not appear RTIS *Judgment and Insight: poor to fair/poor to fair =========================== DISCHARGE PHYSICAL EXAM =========================== 97.9 113/76 72 16 99% RA HEENT: Normocephalic, atraumatic. MMM. Sclerae anicteric. Lungs: No increased work of breathing. CV: Well-perfused Extremities: No edema. Skin: No rashes. Neurological: Cranial Nerves: Face symmetric, EOMI with tracking of examiner, no dysarthria Motor: Moves all extremities symmetrically antigravity. Coordination: No truncal ataxia. *Appearance/behavior: Young woman, adequately groomed, well-nourished, appropriate eye contact, sitting in a chair, no psychomotor agitation *Mood and Affect: "good", appropriate *Thought process: Linear, no LOA *Thought Content: Denies SI/HI or AVH *Judgment and Insight: Intact *Attention, *orientation, and executive function: Awake and alert. Attends during history taking and is able to provide a coherent history. *Speech: Normal rate and volume *Language: Fluent, no paraphasic errors Pertinent Results: ======== LABS ======== ___ 07:50AM BLOOD WBC-7.9# RBC-3.83* Hgb-12.2 Hct-33.6* MCV-88 MCH-31.9 MCHC-36.3 RDW-11.3 RDWSD-36.1 Plt ___ ___ 07:50AM BLOOD Glucose-76 UreaN-4* Creat-0.8 Na-137 K-3.4 Cl-102 HCO3-24 AnGap-14 ___ 07:30PM BLOOD ALT-22 AST-23 AlkPhos-67 TotBili-0.6 ___ 07:30PM BLOOD Lipase-18 ___ 07:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 ___ 05:00AM BLOOD VitB12-331 ___ 05:00AM BLOOD %HbA1c-5.0 eAG-97 ___ 05:00AM BLOOD Triglyc-40 HDL-75 CHOL/HD-2.1 LDLcalc-75 ___ 05:00AM BLOOD TSH-1.3 ___ 02:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:44PM BLOOD Lactate-1.7 HCG, Urine, Qualitative: NEGATIVE RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Norovirus Genogroup I: POSITIVE * Norovirus Genogroup II: NEGATIVE ============== IMAGING ============== CT ABDOMEN AND PELVIS WITH CONTRAST (___): No acute CT findings to explain the patient's lower abdominal pain. Normal appendix and no evidence of pyelonephritis. Brief Hospital Course: Ms. ___ is a ___ year old college student with a past medical history of longstanding depression and anxiety, alcohol use, and PTSD who was admitted ___ with severe depression and a wish to be dead. # Legal/Safety: At presentation, pt signed a CV. She signed a 3-day notice on ___. She was initially placed on red sharp and this was changed to green sharps on ___. She remained on Q15 min checks during hospitalization and was unit restricted and not appropriate for fresh-air groups given elopement risk. Of note, given her good behavioral control throughout her hospitalization with consistent denial of suicidal ideation or thoughts of self harm, I did not believe she met criteria to file a 7&8b. # Psychiatry Patient was admitted to ___ after presenting with worsening symptoms of depression and passive suicidal ideation in the setting of numerous ongoing psychosocial stressors. During her hospitalization, patient was started on low dose Abilify for mood stability and for augmentation of her antidepressant (citalopram) which she tolerated well with no complaints of side effects. For anxiety, we started Vistaril which she tolerated well. She denied any suicidal thoughts and reported a "good" mood on day of discharge. She was enrolled in a partial program at time of discharge. Social work contacted mother, who was in agreement with plan to discharge home with referral to partial program. For her history of substance abuse, pt was offered Nicorette gum and placed on CIWA. She had no signs of alcohol withdrawal. She was also started on a multivitamin, folate, thiamine, and B12 supplementation. Of note, her B12 level was only 331 so she requires ongoing B12 supplementation as an outpatient. # GI During her hospitalization, pt developed nausea and diarrhea. Stool studies returned positive for Norovirus genogroup I. Pt had close electrolyte monitoring and remained clinically and hemodynamically stable. She was placed on isolation precautions during her hospitalization. Her last episode of diarrhea was ___ AM. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 1 mg PO QHS:PRN anxiety/insomnia 2. Escitalopram Oxalate 20 mg PO DAILY 3. Propranolol 10 mg PO TID PRN anxiety, agoraphobia Discharge Medications: 1. ARIPiprazole 1 mg PO DAILY RX *aripiprazole [Abilify] 2 mg 0.5 (One half) tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 2. Cyanocobalamin 500 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. HydrOXYzine 25 mg PO TID:PRN anxiety RX *hydroxyzine HCl 25 mg 1 tab by mouth every eight (8) hours PRN Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY 5. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine cravings RX *nicotine (polacrilex) [Nicorelief] 2 mg chew 1 piece every hour Disp #*1 Packet Refills:*0 6. Escitalopram Oxalate 20 mg PO DAILY 7. Propranolol 10 mg PO TID PRN anxiety, agoraphobia Discharge Disposition: Home Discharge Diagnosis: Unspecified mood disorder PTSD Unspecified Anxiety Disorder Alcohol Use Disorder Norovirus Discharge Condition: 97.9 113/76 72 16 99%RA A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: 'good' A: bright, euthymic, mood congruent, appropriate TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: fair/fair 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: ___
[ "F333", "R45851", "A0811", "F4310", "F1010", "F411", "F4001", "Z915", "F17210", "R350" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I've been hearing voices." Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with history of MDD, GAD, panic disorder with agoraphobia and alcohol use disorder who self-presented with worsening depression, auditory hallucinations in the setting of numerous psychosocial stressors. . On interview, patient expressed that she has been hearing a voice since last night. She explained that she had not heard this voice in [MASKED] years (since she hospitalized at [MASKED]). When asked about recent stressors, she replied, "the usual, school and work." She explained that she attends [MASKED] (studying psychology/juvenile crime) and nannies. She denied depressed mood, hopelessness, anhedonia but endorsed increased sleep (12 h/24h period), low energy/motivation, increased appetite and 'so so' focus (longstanding). She denied SI/HI. . She explained that [MASKED] years ago, the voice initially would just keep her company and would laugh with her. However, since last night, when the voice came back, she expressed that it has been screaming and screaming her name. She expressed she does not recognize the voice but expressed it sounds kind of like her dad's voice but deeper. She denied any other content of the voice outside of wordless screaming and her name. She denied CAH, VH, IOR, TC/TB/TI, paranoid ideation. She denied periods of decreased need for sleep with concurrent distractibility, elevated/irritable mood, grandiosity, racing thoughts, increased goal directed/risky behavior and/or pressured speech. . Patient endorsed 'terrible' anxiety. She expressed that she does not like to leave the house and that this fear of leaving the house has gotten worse over the past few months. She endorsed a fear of something happening while she is on the train that would lead to a crash and her death. She denied any related experience with similar situations. She also endorsed anxiety relating to school, big crowds, unfamiliar people as well as excessive worrying about school and finances to the point that it at times interferes with her daily functioning. . Patient explained that [MASKED] years ago she was hospitalized at [MASKED] while in high school because she was 'super depressed' and heard the aforementioned voice. She expressed that at the time they said she was 'so depressed' that she began to hear voices and started her on Effexor. On follow, patient again denied SI/HI, [MASKED] and expressed a willingness to reach out to mother, outpatient providers, call [MASKED], BEST and return to the ED should she begin to feel unsafe after discharge. She was amenable with scheduling an earlier appointment with Dr. [MASKED] at [MASKED] and to scheduling an intake at an [MASKED] PHP. . Collateral: [MASKED] (mother) [MASKED]: increasing anxiety and depression c this semester, but no concerns relating to safety. Mother denied any safety concerns and felt as though patient was a reliable reporter of safety. Past Medical History: PAST PSYCHIATRIC HISTORY: Diagnosis: ?MDD c psychotic features; per patient, depression and anxiety, alcohol use d/o; per [MASKED], MDD, moderate, recurrent, GAD, panic d/o Hospitalizations: [MASKED] [MASKED] for [MASKED], [MASKED] [MASKED] for ?AH, PHP at [MASKED] before hospitalization Current treaters and treatment: Dr. [MASKED] at [MASKED], no therapist Medication and ECT trials: Effexor (lost weight, withdrawal symptoms if missed dose), Citalopram (works well), Lorazepam (works well), Propranol (works well), Escitalopram (at [MASKED] yo, does not remember), Sertraline (stomach aches), Duloxetine and Gabapentin Self-injury: hit head and tried to OD (Oxy/alcohol) at [MASKED] yo (did not go to hospital), at [MASKED] yo tried to drink self to death (passed out, did not go to hospital), also h/o cutting since [MASKED] yo and headbanging since [MASKED] yo Harm to others: denied Access to weapons: denied PAST MEDICAL HISTORY: PCP: new PCP at [MASKED] (has not yet seen, does not remember name) [MASKED] Social History: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: Brother-?bipolar [MASKED] uncle-?bipolar Physical [MASKED]: =========================== ADMISSION PHYSICAL EXAM =========================== *VS: BP: 140/90 HR: 103 temp: 99.8 resp: 19 O2 sat: 100 Neurological: *station and gait: normal/normal *tone and strength: normal/intact abnormal movements: none appreciated Cognition: Wakefulness/alertness: awake, alert *Attention (MOYB): [MASKED] *Orientation: oriented to person, place, time/date *Memory: Reg [MASKED] Recall [MASKED] at 5 min *Fund of knowledge: [MASKED] recent US presidents Calculations: 2.25=9q Abstraction: apple/orange=fruit *Speech: normal tone, volume, rate, slightly flattened prosody *Language: fluent, normal comprehension Mental Status: *Appearance: appears reported age, dressed in hospital attire, adequate grooming/hygiene Behavior: cooperative, relatively well related, appropriate eye contact *Mood and Affect: 'all right'/somewhat incongruent given tearfulness at times and anxious appearance but otherwise reactive appropriately during interview *Thought process / *associations: linear, coherent/no LOA *Thought Content: denied SI, HI, VH, CAH, endorsed AH but did not appear RTIS *Judgment and Insight: poor to fair/poor to fair =========================== DISCHARGE PHYSICAL EXAM =========================== 97.9 113/76 72 16 99% RA HEENT: Normocephalic, atraumatic. MMM. Sclerae anicteric. Lungs: No increased work of breathing. CV: Well-perfused Extremities: No edema. Skin: No rashes. Neurological: Cranial Nerves: Face symmetric, EOMI with tracking of examiner, no dysarthria Motor: Moves all extremities symmetrically antigravity. Coordination: No truncal ataxia. *Appearance/behavior: Young woman, adequately groomed, well-nourished, appropriate eye contact, sitting in a chair, no psychomotor agitation *Mood and Affect: "good", appropriate *Thought process: Linear, no LOA *Thought Content: Denies SI/HI or AVH *Judgment and Insight: Intact *Attention, *orientation, and executive function: Awake and alert. Attends during history taking and is able to provide a coherent history. *Speech: Normal rate and volume *Language: Fluent, no paraphasic errors Pertinent Results: ======== LABS ======== [MASKED] 07:50AM BLOOD WBC-7.9# RBC-3.83* Hgb-12.2 Hct-33.6* MCV-88 MCH-31.9 MCHC-36.3 RDW-11.3 RDWSD-36.1 Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-76 UreaN-4* Creat-0.8 Na-137 K-3.4 Cl-102 HCO3-24 AnGap-14 [MASKED] 07:30PM BLOOD ALT-22 AST-23 AlkPhos-67 TotBili-0.6 [MASKED] 07:30PM BLOOD Lipase-18 [MASKED] 07:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 [MASKED] 05:00AM BLOOD VitB12-331 [MASKED] 05:00AM BLOOD %HbA1c-5.0 eAG-97 [MASKED] 05:00AM BLOOD Triglyc-40 HDL-75 CHOL/HD-2.1 LDLcalc-75 [MASKED] 05:00AM BLOOD TSH-1.3 [MASKED] 02:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 07:44PM BLOOD Lactate-1.7 HCG, Urine, Qualitative: NEGATIVE RAPID PLASMA REAGIN TEST (Final [MASKED]: NONREACTIVE. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [MASKED]: Negative for Chlamydia trachomatis by [MASKED] System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [MASKED]: Negative for Neisseria gonorrhoeae by [MASKED] System, APTIMA COMBO 2 Assay. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay. URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Norovirus Genogroup I: POSITIVE * Norovirus Genogroup II: NEGATIVE ============== IMAGING ============== CT ABDOMEN AND PELVIS WITH CONTRAST ([MASKED]): No acute CT findings to explain the patient's lower abdominal pain. Normal appendix and no evidence of pyelonephritis. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old college student with a past medical history of longstanding depression and anxiety, alcohol use, and PTSD who was admitted [MASKED] with severe depression and a wish to be dead. # Legal/Safety: At presentation, pt signed a CV. She signed a 3-day notice on [MASKED]. She was initially placed on red sharp and this was changed to green sharps on [MASKED]. She remained on Q15 min checks during hospitalization and was unit restricted and not appropriate for fresh-air groups given elopement risk. Of note, given her good behavioral control throughout her hospitalization with consistent denial of suicidal ideation or thoughts of self harm, I did not believe she met criteria to file a 7&8b. # Psychiatry Patient was admitted to [MASKED] after presenting with worsening symptoms of depression and passive suicidal ideation in the setting of numerous ongoing psychosocial stressors. During her hospitalization, patient was started on low dose Abilify for mood stability and for augmentation of her antidepressant (citalopram) which she tolerated well with no complaints of side effects. For anxiety, we started Vistaril which she tolerated well. She denied any suicidal thoughts and reported a "good" mood on day of discharge. She was enrolled in a partial program at time of discharge. Social work contacted mother, who was in agreement with plan to discharge home with referral to partial program. For her history of substance abuse, pt was offered Nicorette gum and placed on CIWA. She had no signs of alcohol withdrawal. She was also started on a multivitamin, folate, thiamine, and B12 supplementation. Of note, her B12 level was only 331 so she requires ongoing B12 supplementation as an outpatient. # GI During her hospitalization, pt developed nausea and diarrhea. Stool studies returned positive for Norovirus genogroup I. Pt had close electrolyte monitoring and remained clinically and hemodynamically stable. She was placed on isolation precautions during her hospitalization. Her last episode of diarrhea was [MASKED] AM. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 1 mg PO QHS:PRN anxiety/insomnia 2. Escitalopram Oxalate 20 mg PO DAILY 3. Propranolol 10 mg PO TID PRN anxiety, agoraphobia Discharge Medications: 1. ARIPiprazole 1 mg PO DAILY RX *aripiprazole [Abilify] 2 mg 0.5 (One half) tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 2. Cyanocobalamin 500 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. HydrOXYzine 25 mg PO TID:PRN anxiety RX *hydroxyzine HCl 25 mg 1 tab by mouth every eight (8) hours PRN Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY 5. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine cravings RX *nicotine (polacrilex) [Nicorelief] 2 mg chew 1 piece every hour Disp #*1 Packet Refills:*0 6. Escitalopram Oxalate 20 mg PO DAILY 7. Propranolol 10 mg PO TID PRN anxiety, agoraphobia Discharge Disposition: Home Discharge Diagnosis: Unspecified mood disorder PTSD Unspecified Anxiety Disorder Alcohol Use Disorder Norovirus Discharge Condition: 97.9 113/76 72 16 99%RA A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: 'good' A: bright, euthymic, mood congruent, appropriate TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: fair/fair 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" ]
[ "F333: Major depressive disorder, recurrent, severe with psychotic symptoms", "R45851: Suicidal ideations", "A0811: Acute gastroenteropathy due to Norwalk agent", "F4310: Post-traumatic stress disorder, unspecified", "F1010: Alcohol abuse, uncomplicated", "F411: Generalized anxiety disorder", "F4001: Agoraphobia with panic disorder", "Z915: Personal history of self-harm", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R350: Frequency of micturition" ]
10,051,043
22,009,252
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Ms. ___ is a ___ year-old woman with a pertinent past medical history of microscopia polyangiitis (pANCA/MPO+; presented as diffuse alveolar hemorrhages and glomerulonephritis in ___ and hx TIA and CVA (last symptomatic stroke ___ who presented on ___ with left sided weakness to ___ and was transferred today to ___ for further management. Ms. ___ was in her normal state of health (she lives alone with her dog and is an unemployed ___) until 7:40 AM on ___, when she awoke from bed and noted that she was weak on her left side. She found it difficult to get out of bed. When she managed to stand, she felt that her left leg was "wobbly" and she could not walk to get to the bathroom. She says that at 2:40 AM that morning she woke up and used the bathroom before returning back to bed, and she did not perceive any symptoms at that time. She decided to call an ambulance who transported her to ___. ___ discharge summary, patient was noted to be tachycardic (103 bpm), tachypneic (RR23), and hypertensive 153-160/92-103, saturating well on room air. Head CT was done which demonstrated no acute pathology; chest film was done which showed no infiltrate. Code stroke was not called because she was out of the window, but neurology was contacted. NIHSS was 2 for mild ataxia weakness of left arm and subjective numbness of the left arm. She was given 325 mg of oral aspirin. Per patient, she was able to walk yesterday with a walker (patient does not use one at baseline) but she still felt "wobbly" though less so than the day before. Today, she feels like she is regaining her strength back but she is not ___ at her baseline. Her prior stroke was in ___. She presented to ___ with L NLFF and L UE weakness. Of note, had brief episode of diplopia 2 months before. MRI at ___ showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. She had been started on aspirin during her prior ___ stroke but it had been discontinued after diffuse alveolar hemorrhage in ___. She notes a cough which has been present for ___ "months". She does not currently have health insurance secondary to her unemployment and therefore has not had a health maintenace visit in > ___ year and takes no medications. She has a rheumatologist here at the ___. She attests to last having been seen by rheumatology in early ___ after her last vasculitis flare in ___, which was treated with 3 days of pulse methylprednisolone and several weeks of rituximab. Per patient, the course was stopped due to concern for ___ infection due to immunosuppression. On ROS, the pt endorses worsening SOB. She does not note palpitations, but says that her HR has been faster than usual. She denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, or vertigo. Denies difficulties producing or comprehending speech. Denies numbness, parasthesias. No bowel or bladder incontinence or retention. Past Medical History: - MPA (pANCA/MPO) vasculitis with diffuse alveolar hemorrhage and glomerulonephritis. Diagnosed in ___ - initially treated with steroids, plasmapheresis and 6 months of cyslophosphamide. Patient refused to start AZA that rheumatology had recommended after Cytoxan. Last flare in ___ - CVA on ___. Presented to ___ with L NLFF and L UE weakness. Of note, had brief episode of diplopia 2 months before. MRI at ___ showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. - Lyme disease (possible). Per notes, diagnosed in ___. Symptomatic episodes including arthralgias, Raynaud's, extremity pain and weakness. Treated with multiple courses of erythromycin/tetracycline in the past over the course of ___ years with a "Lyme specialist." However, it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis. Social History: ___ Family History: Mother with unknown cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: P: R: BP: SaO2: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: Expiratory wheezes noted bilaterally. Patient has productive cough. Cardiac: Tachycardic, NSR on telemetry, warm, well-perfused Extremities: No ___ edema. Skin: "microvascular" rash notes on ___, baseline from vasculitis per patient Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Could not hear finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 4+ 5- 5- ___ 5 4 4 5 5 R ___ ___ 5 5 5 5 5 -Sensory: No deficits to light touch, cold sensation, vibratory sense, proprioception throughout. Patchy difference on pinprick on lower extremities bilaterally. Romberg absent. -DTRs: ___ Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 1 1 Plantar response was flexor on right and extensor on left. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF, but dysmetria noted on Left HKS. No rebound ataxia. -Gait: Some hesitation. Narrow-based. Spastic. DISCHARGE PHYSICAL EXAM: VS: 97.9 PO 139 / 82 78 18 91 Ra GEN: pleasant, NAD, sitting up in bed, conversant HEENT: sclerae anicteric, MMM, no lesions or thrush, tongue deviated slightly towards the R NECK: supple CV: RRR, normal S1 S2, no murmurs PULM: Prominent crackles throughout b/l heard both posteriorly and anteriorily, decreased breath bilaterally, occasionally coughing during interview ABDM: ND, +bowel sounds, soft, nontender MSK: no joint swelling or erythema EXTR: wwp, no edema SKIN: no rash on lower extremities NEURO: AOx3, CN ___ intact, strength ___ and symmetric in upper and lower extremities, minimal ataxia on L with heel-to-shin Pertinent Results: LABORATORY DATA: ADMISSION LABS: ___: ___: 12.3 PTT: 27.1 ___: 1.___ Glucose: 89 UreaN: 19 Creat: 1.4* Na: 137 K: 4.8 Cl: 100 HCO3: 25 AnGap: 12 ALT: 8 AST: 11 LD(LDH): 182 CK(CPK): 13* AlkPhos: 96 TotBili: 0.3 TotProt: 7.1 Albumin: 3.2* Globuln: 3.9 Calcium: 8.8 Phos: 3.9 Cholest: 132 %HbA1c: 5.4 Triglyc: 133 HDL: 38 LDL: 67 TSH: 3.6 CRP: 43 ___: ___: 12.0 PTT: 25.8 ___: 1.___ Glucose: 92 UreaN: 16 Creat: 1.2* Na: 140 K: 4.2 Cl: 104 HCO3: 26 AnGap: 10 CRP: 22 ESR: 130 HBsAg: Neg HBsAb: Neg HBcAb: Neg HCV: Neg HIV: Neg B2 GLYCOPROTEIN I (IGG)AB <9 (reference <=20 SMU) B2 GLYCOPROTEIN I (IGM)AB <9 (reference <=20 SMU) B2 GLYCOPROTEIN I (IGA)AB <9 (reference <=20 SMU) Cardiolipin Ab: PND Quant-TB Gold: Negative DISCHARGE LABS: ___ 07:35AM BLOOD WBC-7.7 RBC-3.17* Hgb-9.2* Hct-29.0* MCV-92 MCH-29.0 MCHC-31.7* RDW-13.6 RDWSD-46.1 Plt ___ ___ 07:35AM BLOOD Glucose-94 UreaN-18 Creat-1.5* Na-136 K-4.5 Cl-98 HCO3-27 AnGap-11 ___ 07:35AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0 IMAGING STUDIES: Non-Contrast CT of Head (___): No acute intracranial process. No infarct or hemorrhage. MRI w/o contrast (___): - Restricted diffusion of posterior limb of R internal capsule with T2/Flair hyperintensity compatible with a late acute to early subacute infarction. - Probable late acute infarct of posterior R frontal lobe. - ?Punctate lobar foci microbleeds - Probable chronic hemorrhagic infarcts in L external capsule and non hemorrhagic chronic infarcts in basal ganglia. Echocardiogram (___): Normal. LVEF > 55%. No wall motion abnormalities. Trivial (physiologic) mitral regurgitation. Chest (PA & LAT) ___: There is essentially no change compared to the examination from 2 days prior. Heart size is top normal with unfolding of the thoracic aorta and subtle knob calcifications. There is mild to moderate right greater than left pleuroparenchymal scarring. Increased pulmonary interstitial markings appear similar to the prior examination, suggesting a background interstitial lung disease. Otherwise no new consolidation is seen. There is no effusion pneumothorax. There is no acute osseous abnormality. CTA Chest ___: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Nonspecific diffuse multifocal ___, nodular, and ground glass opacities favor an infectious or inflammatory process. The ground-glass component is nonspecific, though could be partially explained by mild diffuse alveolar hemorrhage, given the patient's history. 3. Diffuse cylindrical bronchiectasis and bronchial wall thickening has progressed since ___. 4. Small pericardial effusion. 5. Pulmonary nodules, measuring up to 11 mm in mean diameter. For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. MICROBIOLOGY: ___ 8:15 pm SPUTUM Source: Expectorated. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 9:10 am SPUTUM Site: EXPECTORATED Source: Expectorated. GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 8:34 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): RESULTS PENDING. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunofluorescent test for Pneumocystis jirovecii (carinii) (Final ___: SPECIMEN COMBINED WITH SAMPLE # ___ ___. NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 8:34 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): SPECIMEN COMBINED WITH SAMPLE # ___ ___. No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Preliminary): ___ 8:34 am Rapid Respiratory Viral Screen & Culture RIGHT LOWER LOBE. Respiratory Viral Culture (Preliminary): SPECIMEN COMBINED WITH SAMPLE # ___ ___. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. SPECIMEN COMBINED WITH SAMPLE # ___ ___. BRONCHOSCOPY: ___ Airways were mildly erythematous diffusely. There were purulent secretions in the right middle and lower lobes, and left upper lobe. The right upper, middle, and lower lobe subsegments were inspected, without evidence of mass, mucosal lesions, or other abnormality. The left upper and lower lobe subsegments were inspected without evidence of mass, mucosal lesions, or other abnormality. Serial bronchoalveolar lavage was performed in the right upper lobe apicoposterior segment with return to clear fluid on the first lavage, and slightly pink fluid on the second, findings which are not suggestive of alveolar hemorrhage though do not definitively exclude it. Bronchoalveolar lavage was performed in the right lower lobe with return of pink fluid. No areas of dried blood or previous stigmata of bleeding or alveolar hemorrhage were noted. Brief Hospital Course: ___ with a history of microscopic polyangiitis vasculitis (pANCA/MPO), CVA (___) and several TIAs, who presented to ___ ___ on ___ with L-sided weakness, found to have a subacute stroke, transferred to ___ to neurology service, found to have pAfib with RVR as well as bronchiectasis and multifocal opacities on CT Chest, transferred to medicine for further management. #Subacute stroke, posterior limb of L internal capsule Patient initially presented tp ___ with left sided weakness, transferred to ___ for further stroke work-up and Rheumatology co-management. Patient has a history of multifocal small vessel strokes back in ___. ASA had been started in ___ after her stroke but discontinued in the setting of Diffuse Alveolar Hemorrhage presentation in ___. On presentation here, she had mild weakness on the Left UE and ___ and ___ extensor plantar response on left. No facial weakness or CN involvement. On MRI done at ___, she found to have restricted diffusion of the posterior limb of left internal capsule consistent with new acute stroke, and L parietal subacute stroke. Review of imaging showed the locations of prior chronic infarcts, no additional microhemorrhages were noted on gradient echo. Regarding the etiology of her stroke, the patient as found to have occasional episodes of Afib with RVR (new diagnosis for her), suggesting a cardioembolic source. OSH ECHO was neg for structural abnormalities. Although patient has history of microscopic polyangitis, less likely due to CNS vasculitis because per rheumatology, would only be a concern if patient had extremely active rheumatologic process, which is not her presentation as her renal function is close to her baseline. Furthermore, there was no clear beading / vascular change on CTA to suggest vasculitis. Stroke workup was otherwise negative, CTA did not show significant atherosclerosis or large or medium vessel disease. Patient does not have notable metabolic risk factors. Regarding her course, L-sided weakness and ataxia with significant improvement here. Patient worked with physical therapy and discharged to home with outpatient ___. Started on apixaban for AF after multiple discussions of risks and benefits. Patient was accidentally discharged on ongoing ASA as well; this was an error, as patient has no indication for ASA if she is on apixaban. Multiple attempts made to contact patient by phone without response. Will continue attempting contact. I anticipate that the patient is probably not taking either of these medications due to her reluctance. Also attempted to start patient on atorvastatin on discharge but patient was not amenable to statin treatment. Hypercoagulability workup/APLS testing pending at the time of discharge (b2 glycoprotein, anticardiolipin, lupus anticoagulant). #Paroxysmal Afib with RVR Patient had two episodes of acute tachycardia and felt palpitations. Tele demonstrated irregular rhythm with no distinguishable p waves and HR to 160s c/f Afib with RVR. Went back into sinus rhythm. Per patient, no prior history of Afib. ECHO negative for valvular disease. CHA2DS2VASc (stroke, gender, HTN) of 4, putting her at 4.8%risk per yr. ___ (renal,stroke, bleed) of 3. 4.8% stroke risk per year. Patient initially very hesitant to start anticoagulation but eventually was amenable to starting apixaban. Also started on metoprolol. ASA should be stopped - have attempted to reach patient by phone without success. #Chronic cough and shortness of breath Patient has had a cough productive of white sputum for ___ months, which she states has been improving. She has also had SOB for the past ___ weeks. ___ negative. Patient has not been on immunosupression since last flare in ___ when she presented with hemoptysis, treated with pulse methylpred and Rituximab, stopped when bronch sputum cx grew ___ and ___ Psuedomonas and patient refused triple abx therapy at the time. Patient very hesitant to use abx use after accruing SEs from chronic use of erythromycin/tetracyclines for putative Lyme. ID was consulted to evaluate infx status especially given untreated ___ and Pseudomonas. Found to have extensive bronchiectasis and multifocal opacities on CT Chest as well as ESR 130. Given concern for DAH iso ?active MPA vasculitis flair, bronchoscopy was performed on ___ which demonstrated purulent secretions in the right middle and lower lobes but no strong evidence of alveolar hemorrhage. Thus, etiology of cough/sputum likely thought to be secondary to infection with either ___ and/or pseudomonas. Less likely due to vasculititis because per rheumatology, her pulmonary presentation is not consistent with sequelae of microscopic polyangitis. Prelim cultures (BAL+sputum x2) with oral flora and GNRs, still pending at time of discharge. Respiratory viral screen negative, quantiferon gold negative. HIV/HepB/HepC negative. Given stable respiratory function, patient discharged with plan for f/u with rheum and ID regarding need for abx vs. immunosuppression (e.g. rituximab). Per pulm recs, patient was recommended treatment for preseumed CAP but declined antibiotics at this time. Patient determined to have capacity for this and other decisions, indicating clear understanding of the risks and benefits in the setting of rational thought processes. #renal impairment #ANCA vasculitis Admitted with Cr of 1.4 (baseline 1.3 in ___. History of MPA presenting with glomerulonephritis in ___. Has not had renal biopsy in the past and wast lost to f/u with rheum and nephron clinics after second flare. Kidney function has been stable over the years with Cr and proteinuria at baseline. Sediment showing acanthocytes and dysmorphic red cells. Could be c/f active vasculitis but finding can be seen in chronic ANCA patient w/o flare. Renal biopsy would not be clinically beneficial at this time. Plan for f/u with outpatient nephrologist, Dr. ___. ANCA titer to assess disease activity pending at time of discharge. CORE MEASURES: #Nutrition: Regular #VTE prophylaxis: apixaban #Code status: FC confirmed w patient #Health care proxy/emergency contact: ___ (son) ___ #Consulting Services: Renal, ID, Pulm, Neuro, Rheum Transitional Issues: [] Pt will have follow-up with ID regarding treatment of active pulmonary infections, specifically NTMB, and will require treatment prior to initiation of immunosuppression [] Pt started on apixaban for ongoing anticoagulation given her history of atrial fibrillation and stroke [] Pt will need to establish a new primary care doctor in the next week when her insurance coverage is more stable, and we discussed the importance of this with her prior to discharge. [] Continue to attempt contact with patient to instruct her not to take ASA while taking apixaban Medications on Admission: No medications. Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5.Outpatient Physical Therapy Evaluate and Treatment ___ weeks, 3x/wk ICD-10 J47.9 Bronchiectasis, uncomplicated Discharge Disposition: Home Discharge Diagnosis: Subacute stroke, posterior limb of L internal capsule Paroxysmal Afib with RVR Microscopic polyangiitis vasculitis 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: WHY YOU CAME TO THE HOSPITAL - You were having weakness in your left leg - You had also been having a cough for the past few months - You originally went to ___, and you were transferred to ___ for further care WHAT WE DID IN THE HOSPITAL - You had an MRI of your brain, which showed that you had a stroke on the right side of your brain - You had a CT scan of your lungs, which showed a significant amount of inflammation in your lungs - You had a bronchoscopy, which did not show any bleeding in your lungs but did show inflammation. We took samples of the fluid in your lungs to check for an infection WHAT YOU NEED TO DO WHEN YOU GET HOME -Please take the Eliquis, metoprolol, and atorvastatin as prescribed -Please schedule an appointment to work with a physical therapist. We have given you a prescription you can bring to any physical therapist. -Please follow up with Dr. ___ (Infectious Disease), Dr. ___ (Kidney), and Dr. ___ ___ (Rheumatology). You will need to call to make a new primary care appointment Followup Instructions: ___
[ "I63432", "M317", "G8194", "I480", "I7789", "J479", "R29702", "R270", "Z8673" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Ms. [MASKED] is a [MASKED] year-old woman with a pertinent past medical history of microscopia polyangiitis (pANCA/MPO+; presented as diffuse alveolar hemorrhages and glomerulonephritis in [MASKED] and hx TIA and CVA (last symptomatic stroke [MASKED] who presented on [MASKED] with left sided weakness to [MASKED] and was transferred today to [MASKED] for further management. Ms. [MASKED] was in her normal state of health (she lives alone with her dog and is an unemployed [MASKED]) until 7:40 AM on [MASKED], when she awoke from bed and noted that she was weak on her left side. She found it difficult to get out of bed. When she managed to stand, she felt that her left leg was "wobbly" and she could not walk to get to the bathroom. She says that at 2:40 AM that morning she woke up and used the bathroom before returning back to bed, and she did not perceive any symptoms at that time. She decided to call an ambulance who transported her to [MASKED]. [MASKED] discharge summary, patient was noted to be tachycardic (103 bpm), tachypneic (RR23), and hypertensive 153-160/92-103, saturating well on room air. Head CT was done which demonstrated no acute pathology; chest film was done which showed no infiltrate. Code stroke was not called because she was out of the window, but neurology was contacted. NIHSS was 2 for mild ataxia weakness of left arm and subjective numbness of the left arm. She was given 325 mg of oral aspirin. Per patient, she was able to walk yesterday with a walker (patient does not use one at baseline) but she still felt "wobbly" though less so than the day before. Today, she feels like she is regaining her strength back but she is not [MASKED] at her baseline. Her prior stroke was in [MASKED]. She presented to [MASKED] with L NLFF and L UE weakness. Of note, had brief episode of diplopia 2 months before. MRI at [MASKED] showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. She had been started on aspirin during her prior [MASKED] stroke but it had been discontinued after diffuse alveolar hemorrhage in [MASKED]. She notes a cough which has been present for [MASKED] "months". She does not currently have health insurance secondary to her unemployment and therefore has not had a health maintenace visit in > [MASKED] year and takes no medications. She has a rheumatologist here at the [MASKED]. She attests to last having been seen by rheumatology in early [MASKED] after her last vasculitis flare in [MASKED], which was treated with 3 days of pulse methylprednisolone and several weeks of rituximab. Per patient, the course was stopped due to concern for [MASKED] infection due to immunosuppression. On ROS, the pt endorses worsening SOB. She does not note palpitations, but says that her HR has been faster than usual. She denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, or vertigo. Denies difficulties producing or comprehending speech. Denies numbness, parasthesias. No bowel or bladder incontinence or retention. Past Medical History: - MPA (pANCA/MPO) vasculitis with diffuse alveolar hemorrhage and glomerulonephritis. Diagnosed in [MASKED] - initially treated with steroids, plasmapheresis and 6 months of cyslophosphamide. Patient refused to start AZA that rheumatology had recommended after Cytoxan. Last flare in [MASKED] - CVA on [MASKED]. Presented to [MASKED] with L NLFF and L UE weakness. Of note, had brief episode of diplopia 2 months before. MRI at [MASKED] showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. - Lyme disease (possible). Per notes, diagnosed in [MASKED]. Symptomatic episodes including arthralgias, Raynaud's, extremity pain and weakness. Treated with multiple courses of erythromycin/tetracycline in the past over the course of [MASKED] years with a "Lyme specialist." However, it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis. Social History: [MASKED] Family History: Mother with unknown cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: P: R: BP: SaO2: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: Expiratory wheezes noted bilaterally. Patient has productive cough. Cardiac: Tachycardic, NSR on telemetry, warm, well-perfused Extremities: No [MASKED] edema. Skin: "microvascular" rash notes on [MASKED], baseline from vasculitis per patient Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Could not hear 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, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 4+ 5- 5- [MASKED] 5 4 4 5 5 R [MASKED] [MASKED] 5 5 5 5 5 -Sensory: No deficits to light touch, cold sensation, vibratory sense, proprioception throughout. Patchy difference on pinprick on lower extremities bilaterally. Romberg absent. -DTRs: [MASKED] Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 1 1 Plantar response was flexor on right and extensor on left. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF, but dysmetria noted on Left HKS. No rebound ataxia. -Gait: Some hesitation. Narrow-based. Spastic. DISCHARGE PHYSICAL EXAM: VS: 97.9 PO 139 / 82 78 18 91 Ra GEN: pleasant, NAD, sitting up in bed, conversant HEENT: sclerae anicteric, MMM, no lesions or thrush, tongue deviated slightly towards the R NECK: supple CV: RRR, normal S1 S2, no murmurs PULM: Prominent crackles throughout b/l heard both posteriorly and anteriorily, decreased breath bilaterally, occasionally coughing during interview ABDM: ND, +bowel sounds, soft, nontender MSK: no joint swelling or erythema EXTR: wwp, no edema SKIN: no rash on lower extremities NEURO: AOx3, CN [MASKED] intact, strength [MASKED] and symmetric in upper and lower extremities, minimal ataxia on L with heel-to-shin Pertinent Results: LABORATORY DATA: ADMISSION LABS: [MASKED]: [MASKED]: 12.3 PTT: 27.1 [MASKED]: 1.[MASKED] Glucose: 89 UreaN: 19 Creat: 1.4* Na: 137 K: 4.8 Cl: 100 HCO3: 25 AnGap: 12 ALT: 8 AST: 11 LD(LDH): 182 CK(CPK): 13* AlkPhos: 96 TotBili: 0.3 TotProt: 7.1 Albumin: 3.2* Globuln: 3.9 Calcium: 8.8 Phos: 3.9 Cholest: 132 %HbA1c: 5.4 Triglyc: 133 HDL: 38 LDL: 67 TSH: 3.6 CRP: 43 [MASKED]: [MASKED]: 12.0 PTT: 25.8 [MASKED]: 1.[MASKED] Glucose: 92 UreaN: 16 Creat: 1.2* Na: 140 K: 4.2 Cl: 104 HCO3: 26 AnGap: 10 CRP: 22 ESR: 130 HBsAg: Neg HBsAb: Neg HBcAb: Neg HCV: Neg HIV: Neg B2 GLYCOPROTEIN I (IGG)AB <9 (reference <=20 SMU) B2 GLYCOPROTEIN I (IGM)AB <9 (reference <=20 SMU) B2 GLYCOPROTEIN I (IGA)AB <9 (reference <=20 SMU) Cardiolipin Ab: PND Quant-TB Gold: Negative DISCHARGE LABS: [MASKED] 07:35AM BLOOD WBC-7.7 RBC-3.17* Hgb-9.2* Hct-29.0* MCV-92 MCH-29.0 MCHC-31.7* RDW-13.6 RDWSD-46.1 Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-94 UreaN-18 Creat-1.5* Na-136 K-4.5 Cl-98 HCO3-27 AnGap-11 [MASKED] 07:35AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0 IMAGING STUDIES: Non-Contrast CT of Head ([MASKED]): No acute intracranial process. No infarct or hemorrhage. MRI w/o contrast ([MASKED]): - Restricted diffusion of posterior limb of R internal capsule with T2/Flair hyperintensity compatible with a late acute to early subacute infarction. - Probable late acute infarct of posterior R frontal lobe. - ?Punctate lobar foci microbleeds - Probable chronic hemorrhagic infarcts in L external capsule and non hemorrhagic chronic infarcts in basal ganglia. Echocardiogram ([MASKED]): Normal. LVEF > 55%. No wall motion abnormalities. Trivial (physiologic) mitral regurgitation. Chest (PA & LAT) [MASKED]: There is essentially no change compared to the examination from 2 days prior. Heart size is top normal with unfolding of the thoracic aorta and subtle knob calcifications. There is mild to moderate right greater than left pleuroparenchymal scarring. Increased pulmonary interstitial markings appear similar to the prior examination, suggesting a background interstitial lung disease. Otherwise no new consolidation is seen. There is no effusion pneumothorax. There is no acute osseous abnormality. CTA Chest [MASKED]: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Nonspecific diffuse multifocal [MASKED], nodular, and ground glass opacities favor an infectious or inflammatory process. The ground-glass component is nonspecific, though could be partially explained by mild diffuse alveolar hemorrhage, given the patient's history. 3. Diffuse cylindrical bronchiectasis and bronchial wall thickening has progressed since [MASKED]. 4. Small pericardial effusion. 5. Pulmonary nodules, measuring up to 11 mm in mean diameter. For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. MICROBIOLOGY: [MASKED] 8:15 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] 9:10 am SPUTUM Site: EXPECTORATED Source: Expectorated. GRAM STAIN (Final [MASKED]: [MASKED] PMNs and <10 epithelial cells/100X field. 2+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ [MASKED] per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] 8:34 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): RESULTS PENDING. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [MASKED]: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ([MASKED]). Immunofluorescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: SPECIMEN COMBINED WITH SAMPLE # [MASKED] [MASKED]. NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] 8:34 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): SPECIMEN COMBINED WITH SAMPLE # [MASKED] [MASKED]. No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Preliminary): [MASKED] 8:34 am Rapid Respiratory Viral Screen & Culture RIGHT LOWER LOBE. Respiratory Viral Culture (Preliminary): SPECIMEN COMBINED WITH SAMPLE # [MASKED] [MASKED]. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. SPECIMEN COMBINED WITH SAMPLE # [MASKED] [MASKED]. BRONCHOSCOPY: [MASKED] Airways were mildly erythematous diffusely. There were purulent secretions in the right middle and lower lobes, and left upper lobe. The right upper, middle, and lower lobe subsegments were inspected, without evidence of mass, mucosal lesions, or other abnormality. The left upper and lower lobe subsegments were inspected without evidence of mass, mucosal lesions, or other abnormality. Serial bronchoalveolar lavage was performed in the right upper lobe apicoposterior segment with return to clear fluid on the first lavage, and slightly pink fluid on the second, findings which are not suggestive of alveolar hemorrhage though do not definitively exclude it. Bronchoalveolar lavage was performed in the right lower lobe with return of pink fluid. No areas of dried blood or previous stigmata of bleeding or alveolar hemorrhage were noted. Brief Hospital Course: [MASKED] with a history of microscopic polyangiitis vasculitis (pANCA/MPO), CVA ([MASKED]) and several TIAs, who presented to [MASKED] [MASKED] on [MASKED] with L-sided weakness, found to have a subacute stroke, transferred to [MASKED] to neurology service, found to have pAfib with RVR as well as bronchiectasis and multifocal opacities on CT Chest, transferred to medicine for further management. #Subacute stroke, posterior limb of L internal capsule Patient initially presented tp [MASKED] with left sided weakness, transferred to [MASKED] for further stroke work-up and Rheumatology co-management. Patient has a history of multifocal small vessel strokes back in [MASKED]. ASA had been started in [MASKED] after her stroke but discontinued in the setting of Diffuse Alveolar Hemorrhage presentation in [MASKED]. On presentation here, she had mild weakness on the Left UE and [MASKED] and [MASKED] extensor plantar response on left. No facial weakness or CN involvement. On MRI done at [MASKED], she found to have restricted diffusion of the posterior limb of left internal capsule consistent with new acute stroke, and L parietal subacute stroke. Review of imaging showed the locations of prior chronic infarcts, no additional microhemorrhages were noted on gradient echo. Regarding the etiology of her stroke, the patient as found to have occasional episodes of Afib with RVR (new diagnosis for her), suggesting a cardioembolic source. OSH ECHO was neg for structural abnormalities. Although patient has history of microscopic polyangitis, less likely due to CNS vasculitis because per rheumatology, would only be a concern if patient had extremely active rheumatologic process, which is not her presentation as her renal function is close to her baseline. Furthermore, there was no clear beading / vascular change on CTA to suggest vasculitis. Stroke workup was otherwise negative, CTA did not show significant atherosclerosis or large or medium vessel disease. Patient does not have notable metabolic risk factors. Regarding her course, L-sided weakness and ataxia with significant improvement here. Patient worked with physical therapy and discharged to home with outpatient [MASKED]. Started on apixaban for AF after multiple discussions of risks and benefits. Patient was accidentally discharged on ongoing ASA as well; this was an error, as patient has no indication for ASA if she is on apixaban. Multiple attempts made to contact patient by phone without response. Will continue attempting contact. I anticipate that the patient is probably not taking either of these medications due to her reluctance. Also attempted to start patient on atorvastatin on discharge but patient was not amenable to statin treatment. Hypercoagulability workup/APLS testing pending at the time of discharge (b2 glycoprotein, anticardiolipin, lupus anticoagulant). #Paroxysmal Afib with RVR Patient had two episodes of acute tachycardia and felt palpitations. Tele demonstrated irregular rhythm with no distinguishable p waves and HR to 160s c/f Afib with RVR. Went back into sinus rhythm. Per patient, no prior history of Afib. ECHO negative for valvular disease. CHA2DS2VASc (stroke, gender, HTN) of 4, putting her at 4.8%risk per yr. [MASKED] (renal,stroke, bleed) of 3. 4.8% stroke risk per year. Patient initially very hesitant to start anticoagulation but eventually was amenable to starting apixaban. Also started on metoprolol. ASA should be stopped - have attempted to reach patient by phone without success. #Chronic cough and shortness of breath Patient has had a cough productive of white sputum for [MASKED] months, which she states has been improving. She has also had SOB for the past [MASKED] weeks. [MASKED] negative. Patient has not been on immunosupression since last flare in [MASKED] when she presented with hemoptysis, treated with pulse methylpred and Rituximab, stopped when bronch sputum cx grew [MASKED] and [MASKED] Psuedomonas and patient refused triple abx therapy at the time. Patient very hesitant to use abx use after accruing SEs from chronic use of erythromycin/tetracyclines for putative Lyme. ID was consulted to evaluate infx status especially given untreated [MASKED] and Pseudomonas. Found to have extensive bronchiectasis and multifocal opacities on CT Chest as well as ESR 130. Given concern for DAH iso ?active MPA vasculitis flair, bronchoscopy was performed on [MASKED] which demonstrated purulent secretions in the right middle and lower lobes but no strong evidence of alveolar hemorrhage. Thus, etiology of cough/sputum likely thought to be secondary to infection with either [MASKED] and/or pseudomonas. Less likely due to vasculititis because per rheumatology, her pulmonary presentation is not consistent with sequelae of microscopic polyangitis. Prelim cultures (BAL+sputum x2) with oral flora and GNRs, still pending at time of discharge. Respiratory viral screen negative, quantiferon gold negative. HIV/HepB/HepC negative. Given stable respiratory function, patient discharged with plan for f/u with rheum and ID regarding need for abx vs. immunosuppression (e.g. rituximab). Per pulm recs, patient was recommended treatment for preseumed CAP but declined antibiotics at this time. Patient determined to have capacity for this and other decisions, indicating clear understanding of the risks and benefits in the setting of rational thought processes. #renal impairment #ANCA vasculitis Admitted with Cr of 1.4 (baseline 1.3 in [MASKED]. History of MPA presenting with glomerulonephritis in [MASKED]. Has not had renal biopsy in the past and wast lost to f/u with rheum and nephron clinics after second flare. Kidney function has been stable over the years with Cr and proteinuria at baseline. Sediment showing acanthocytes and dysmorphic red cells. Could be c/f active vasculitis but finding can be seen in chronic ANCA patient w/o flare. Renal biopsy would not be clinically beneficial at this time. Plan for f/u with outpatient nephrologist, Dr. [MASKED]. ANCA titer to assess disease activity pending at time of discharge. CORE MEASURES: #Nutrition: Regular #VTE prophylaxis: apixaban #Code status: FC confirmed w patient #Health care proxy/emergency contact: [MASKED] (son) [MASKED] #Consulting Services: Renal, ID, Pulm, Neuro, Rheum Transitional Issues: [] Pt will have follow-up with ID regarding treatment of active pulmonary infections, specifically NTMB, and will require treatment prior to initiation of immunosuppression [] Pt started on apixaban for ongoing anticoagulation given her history of atrial fibrillation and stroke [] Pt will need to establish a new primary care doctor in the next week when her insurance coverage is more stable, and we discussed the importance of this with her prior to discharge. [] Continue to attempt contact with patient to instruct her not to take ASA while taking apixaban Medications on Admission: No medications. Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5.Outpatient Physical Therapy Evaluate and Treatment [MASKED] weeks, 3x/wk ICD-10 J47.9 Bronchiectasis, uncomplicated Discharge Disposition: Home Discharge Diagnosis: Subacute stroke, posterior limb of L internal capsule Paroxysmal Afib with RVR Microscopic polyangiitis vasculitis 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: WHY YOU CAME TO THE HOSPITAL - You were having weakness in your left leg - You had also been having a cough for the past few months - You originally went to [MASKED], and you were transferred to [MASKED] for further care WHAT WE DID IN THE HOSPITAL - You had an MRI of your brain, which showed that you had a stroke on the right side of your brain - You had a CT scan of your lungs, which showed a significant amount of inflammation in your lungs - You had a bronchoscopy, which did not show any bleeding in your lungs but did show inflammation. We took samples of the fluid in your lungs to check for an infection WHAT YOU NEED TO DO WHEN YOU GET HOME -Please take the Eliquis, metoprolol, and atorvastatin as prescribed -Please schedule an appointment to work with a physical therapist. We have given you a prescription you can bring to any physical therapist. -Please follow up with Dr. [MASKED] (Infectious Disease), Dr. [MASKED] (Kidney), and Dr. [MASKED] [MASKED] (Rheumatology). You will need to call to make a new primary care appointment Followup Instructions: [MASKED]
[]
[ "I480", "Z8673" ]
[ "I63432: Cerebral infarction due to embolism of left posterior cerebral artery", "M317: Microscopic polyangiitis", "G8194: Hemiplegia, unspecified affecting left nondominant side", "I480: Paroxysmal atrial fibrillation", "I7789: Other specified disorders of arteries and arterioles", "J479: Bronchiectasis, uncomplicated", "R29702: NIHSS score 2", "R270: Ataxia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,051,043
25,409,423
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea on exertion, difficulty managing anticoagulation Major Surgical or Invasive Procedure: ___ ___ implant (Left atrial appendage device) History of Present Illness: ___ old female with h/o HTN, paroxysmal atrial fibrillation, multiple embolic CVA, microscopic polyangiitism, ANCA vasculitis treated with steroids, CKD, mycobacterial lung infection, and SAH ___ s/p craniotomy and clip ligation in ___, referred for ___ implant as she has a history of medication non compliance (previously not compliant with Eliquis) currently on Coumadin. Past Medical History: CKD (chronic kidney disease), stage IV Subarachnoid hemorrhage ___ S/P craniotomy/L ICA bifurcation aneurysm Microscopic polyangiitis Cerebrovascular accident due to embolism paroxysmal atrial fibrillation Cerebrovascular accident due to embolism of vertebral artery, unspecified blood vessel laterality Anticoagulant long-term use Social History: ___ Family History: Patient does not believe there is a family history of aneurysms. Mother with unknown cancer. Physical Exam: ADMISSION PE: VS: BP 120/77 HR 73 RR 18 SpO2 99% 2Lnc Gen: Patient is in no acute distress. HEENT: Face symmetrical, Eyes: PERRL bilaterally, trachea midline. Neuro: A/Ox3. Able to answer questions and follow commands. No focal deficits. No tongue deviation. Able to give thumbs up bilaterally and wiggle toes bilaterally. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 2+. Access: Right femoral access site soft, tender with palpation. No swelling, drainage or hematoma noted. No bruits ausculated. Abd: Rounded, soft, non-tender. ======================================== DISCHARGE PE: VS: T 98.2F, HR 88, RR 20, O2 sat 94% on RA, BP 136/71 Weight: 55.8 kg, 123.0 lbs Telemetry: SR HR 70-100; no events Gen: Sitting up in bed, NAD Neuro: A&O to self, place, setting, month, year. Pleasant and conversant, no further garbled, speech clear. RUE ___, all other extremities ___. no sensory deficits noted, + facial symmetry. HEENT: normocephalic, anicteric, oropharynx moist Neck: supple, trachea midline, no JVD CV: RRR, S1S2 Pulm: LS CTA bilaterally, non-labored breathing ABD: soft, nontender, BS x4 Extr: No edema bilaterally, 2+ ___, DP Skin: warm, dry, intact, no open lesions Access sites: R groin suture removed, tender to palpation, mild ecchymosis, small hematoma GU: voiding independently Pertinent Results: ___: EP REPORT: Successful implant of 21mm Watchman device in the ___ via the right femoral vein without complications. - 6 hours of bedrest - overnight observation - aspirin 81mg daily - c/w warfarin - TEE in 45 days - f/u with Dr. ___ 1 month ==================================== ___: HEAD CT "No intracranial hemorrhage. Multifocal small hypodensities within the bilateral basal ganglia, corona radiata, and periventricular white matter may correspond to chronic lacunar infarcts and microangiopathy. MRI could be obtained to better assess for acute infarct." ==================================== ___ MRI FINDINGS: Artifact in the left frontal region from aneurysm clip limits evaluation in this area. There are scattered elongated foci of slow diffusion in the left greater than right centrum semiovale and corona radiata compatible with small acute infarctions. There are multiple small chronic infarctions in the left greater than right centrum semiovale and bilateral basal ganglia. Additional punctate infarctions are noted in the pons. Gradient recalled echo images demonstrate multiple punctate foci of hypointense signal, predominantly in a peripheral distribution. Findings are most consistent with cerebral amyloid angiopathy. Again seen and unchanged is superficial siderosis in the left sylvian fissure. Patchy to confluent areas of T2 and FLAIR hyperintense signal abnormalities in the periventricular and subcortical white matter are nonspecific, but likely reflect chronic small vessel ischemic changes. Mild prominence of the ventricles and sulci is suggestive of involutional changes. There is no mass effect or midline shift. There are dilated perivascular spaces. There is mild mucosal thickening of the paranasal sinuses. Mild fluid signal is seen in the bilateral mastoid air cells. The intraorbital contents are unremarkable. IMPRESSION: 1. Small acute infarctions in the left greater than right centrum semiovale and corona radiata. The findings are typical for hypoperfusion and watershed infarctions. 2. Multiple small chronic infarctions in the bilateral centrum semiovale and basal ganglia as well as the pons. 3. Findings of cerebral amyloid angiopathy. 4. Mild parenchymal volume loss. 5. Probable extensive chronic small vessel ischemic disease. ========================================= ___: TTE CONCLUSION: There is normal left ventricular wall thickness with a normal cavity size. There is normal regional left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). Normal right ventricular cavity size with normal free wall motion. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is a trivial pericardial effusion. Neither the left atrial appendage nor the ___ occluder device were well-visualized. Compared with the prior TTE ___ RECOMMEND: If clinically indicated, a TEE is suggested for further evaluation of Watchman device Brief Hospital Course: Ms. ___ is a ___ year old female with h/o HTN, CKD, microscopic polyangiitism, ANCA vasculitis treated with steroids, paroxysmal atrial fibrillation, multiple embolic strokes, ___ ___ s/p craniotomy and clip ligation ___ referred for Watchman implant as she has h/o medication non-compliance with Eliquis. She has been on Coumadin with therapeutic INRs since ___. She underwent successful #21 ___ implant ___. Post procedure course was complicated by RUE weakness in the PACU with word finding difficulty. Code stroke called, CT imaging unremarkable. MRI overnight was significant for small embolic infarcts bilaterally, left greater than right, typical for watershed event. # Atrial fibrillation with history of SAH: s/p Watchman implant ___ device) ___ complicated by small embolic stroke. - ASA 81 mg daily - Continue Warfarin 5.5mg daily for 45 days, with weekly INRs for the next ___ days. - Unable to switch to Apixiban at this time due to deductible of $416/month for first month - SBE prophylaxis x 6 mos post-procedure - Follow up TEE in 45 days; Follow up with NP ___ # Embolic CVA: RUE weakness with +pronator drift and garbled speech, code stroke called, with CT and MRI results as above. Seen by acute ___ while in patient with recommendation for acute rehab. - Appreciate neurology recommendations. - Keep HOB at 30 deg for aspiration precautions and to maximize cerebral perfusion - Allow BP to autoregulate - No need for stroke work up labs given that she was worked up recently and risk factors known; follow up with neurology as previously scheduled - Continue current anticoagulation regimen - Patient has now been seen by ___, OT, S/S - Appreciate ___ recommendations: acute rehab - Appreciate Speech and Swallow recommendations 1. Diet: NECTAR thick liquids, REGULAR solids 2. Medications: whole in puree 3. Aspiration precautions: - strict 1:1 assist - ensure SMALL bites/sips - ensure SLOW rate - cup sips only - no straws - reduce distractions: no talking, lights on, TV off, phone put away 4. TID oral care 5. If continued dysphonia, pt may benefit from further workup by ENT and may also benefit from voice therapy upon d/c as an outpatient/within home. # GI/Nutrition: - diet as above - Cardiac heart healthy diet once passes - Bowel regimen with Senna, MiraLax # Renal: Baseline Cr: 1.9, 1.6 today - Continue to trend # Psychiatric/Behavioral: mood stable - No active issues # DISPO: To ___ Acute Rehab on ___ # Transitional: [ ] Continue Warfarin for next ___ days with weekly INRs [ ] TEE in 45 days as schedule; follow up with ___ NP as scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. CARVedilol 3.125 mg PO BID 3. Warfarin 5.5 mg PO DAILY16 4. NIFEdipine (Extended Release) 60 mg PO DAILY 5. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 3. Atorvastatin 40 mg PO QPM 4. CARVedilol 3.125 mg PO BID 5. NIFEdipine (Extended Release) 60 mg PO DAILY 6. Warfarin 5.5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Subarachnoid hemorrhage ___ s/p craniotomy and clip ligation - Paroxysmal Atrial Fibrillation on Warfarin with high risk for bleeding now s/p Watchman device - Periprocedural Embolic CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. WHY WAS I IN THE HOSPITAL & WHAT HAPPENDED IN THE HOSPITAL? =========================================================== - You had a Watchman device implanted to decrease the risk of stroke due to atrial fibrillation. - You developed right arm weakness after the procedure and an MRI of your head confirmed you had new areas of small strokes. - The weakness in your right arm and your difficulty with speech is much improved. - The Neurology team & the Physical and Occupational therapists agree that you will need acute rehab for continued work with speech, ___ and OT. WHAT SHOULD I DO WHEN I GO HOME? ================================ -Take all of your medications as prescribed (listed below). -CONTINUE taking your Warfarin, for at least the next ___ days and then otherwise directed by Dr. ___. You are currently taking 5.5mg once daily. Your INR 2.7 today. When you are discharged from rehab, ___ Anticoagulation will continue to follow your INRs. -You should also continue to take Aspirin 81mg daily. - Activity restrictions and information related to care of the access sites in the groin are included in your discharge instructions. - You will need prophylactic antibiotics prior to any dental procedure for the next 6 months. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure including dental cleanings. - Follow up with your doctors as listed below It was a pleasure participating in your care. If you have any urgent questions that are related to your recovery from your hospitalization 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. -Your ___ Care Team Followup Instructions: ___
[ "I480", "I6340", "I97820", "E854", "N184", "M317", "Z7901", "G8321", "R4789", "Y848", "Y92230", "R29703", "I680", "Z006", "I129", "Z8673", "I776", "Z9114" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion, difficulty managing anticoagulation Major Surgical or Invasive Procedure: [MASKED] [MASKED] implant (Left atrial appendage device) History of Present Illness: [MASKED] old female with h/o HTN, paroxysmal atrial fibrillation, multiple embolic CVA, microscopic polyangiitism, ANCA vasculitis treated with steroids, CKD, mycobacterial lung infection, and SAH [MASKED] s/p craniotomy and clip ligation in [MASKED], referred for [MASKED] implant as she has a history of medication non compliance (previously not compliant with Eliquis) currently on Coumadin. Past Medical History: CKD (chronic kidney disease), stage IV Subarachnoid hemorrhage [MASKED] S/P craniotomy/L ICA bifurcation aneurysm Microscopic polyangiitis Cerebrovascular accident due to embolism paroxysmal atrial fibrillation Cerebrovascular accident due to embolism of vertebral artery, unspecified blood vessel laterality Anticoagulant long-term use Social History: [MASKED] Family History: Patient does not believe there is a family history of aneurysms. Mother with unknown cancer. Physical Exam: ADMISSION PE: VS: BP 120/77 HR 73 RR 18 SpO2 99% 2Lnc Gen: Patient is in no acute distress. HEENT: Face symmetrical, Eyes: PERRL bilaterally, trachea midline. Neuro: A/Ox3. Able to answer questions and follow commands. No focal deficits. No tongue deviation. Able to give thumbs up bilaterally and wiggle toes bilaterally. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, [MASKED] pulses palpable 2+. Access: Right femoral access site soft, tender with palpation. No swelling, drainage or hematoma noted. No bruits ausculated. Abd: Rounded, soft, non-tender. ======================================== DISCHARGE PE: VS: T 98.2F, HR 88, RR 20, O2 sat 94% on RA, BP 136/71 Weight: 55.8 kg, 123.0 lbs Telemetry: SR HR 70-100; no events Gen: Sitting up in bed, NAD Neuro: A&O to self, place, setting, month, year. Pleasant and conversant, no further garbled, speech clear. RUE [MASKED], all other extremities [MASKED]. no sensory deficits noted, + facial symmetry. HEENT: normocephalic, anicteric, oropharynx moist Neck: supple, trachea midline, no JVD CV: RRR, S1S2 Pulm: LS CTA bilaterally, non-labored breathing ABD: soft, nontender, BS x4 Extr: No edema bilaterally, 2+ [MASKED], DP Skin: warm, dry, intact, no open lesions Access sites: R groin suture removed, tender to palpation, mild ecchymosis, small hematoma GU: voiding independently Pertinent Results: [MASKED]: EP REPORT: Successful implant of 21mm Watchman device in the [MASKED] via the right femoral vein without complications. - 6 hours of bedrest - overnight observation - aspirin 81mg daily - c/w warfarin - TEE in 45 days - f/u with Dr. [MASKED] 1 month ==================================== [MASKED]: HEAD CT "No intracranial hemorrhage. Multifocal small hypodensities within the bilateral basal ganglia, corona radiata, and periventricular white matter may correspond to chronic lacunar infarcts and microangiopathy. MRI could be obtained to better assess for acute infarct." ==================================== [MASKED] MRI FINDINGS: Artifact in the left frontal region from aneurysm clip limits evaluation in this area. There are scattered elongated foci of slow diffusion in the left greater than right centrum semiovale and corona radiata compatible with small acute infarctions. There are multiple small chronic infarctions in the left greater than right centrum semiovale and bilateral basal ganglia. Additional punctate infarctions are noted in the pons. Gradient recalled echo images demonstrate multiple punctate foci of hypointense signal, predominantly in a peripheral distribution. Findings are most consistent with cerebral amyloid angiopathy. Again seen and unchanged is superficial siderosis in the left sylvian fissure. Patchy to confluent areas of T2 and FLAIR hyperintense signal abnormalities in the periventricular and subcortical white matter are nonspecific, but likely reflect chronic small vessel ischemic changes. Mild prominence of the ventricles and sulci is suggestive of involutional changes. There is no mass effect or midline shift. There are dilated perivascular spaces. There is mild mucosal thickening of the paranasal sinuses. Mild fluid signal is seen in the bilateral mastoid air cells. The intraorbital contents are unremarkable. IMPRESSION: 1. Small acute infarctions in the left greater than right centrum semiovale and corona radiata. The findings are typical for hypoperfusion and watershed infarctions. 2. Multiple small chronic infarctions in the bilateral centrum semiovale and basal ganglia as well as the pons. 3. Findings of cerebral amyloid angiopathy. 4. Mild parenchymal volume loss. 5. Probable extensive chronic small vessel ischemic disease. ========================================= [MASKED]: TTE CONCLUSION: There is normal left ventricular wall thickness with a normal cavity size. There is normal regional left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). Normal right ventricular cavity size with normal free wall motion. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is a trivial pericardial effusion. Neither the left atrial appendage nor the [MASKED] occluder device were well-visualized. Compared with the prior TTE [MASKED] RECOMMEND: If clinically indicated, a TEE is suggested for further evaluation of Watchman device Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female with h/o HTN, CKD, microscopic polyangiitism, ANCA vasculitis treated with steroids, paroxysmal atrial fibrillation, multiple embolic strokes, [MASKED] [MASKED] s/p craniotomy and clip ligation [MASKED] referred for Watchman implant as she has h/o medication non-compliance with Eliquis. She has been on Coumadin with therapeutic INRs since [MASKED]. She underwent successful #21 [MASKED] implant [MASKED]. Post procedure course was complicated by RUE weakness in the PACU with word finding difficulty. Code stroke called, CT imaging unremarkable. MRI overnight was significant for small embolic infarcts bilaterally, left greater than right, typical for watershed event. # Atrial fibrillation with history of SAH: s/p Watchman implant [MASKED] device) [MASKED] complicated by small embolic stroke. - ASA 81 mg daily - Continue Warfarin 5.5mg daily for 45 days, with weekly INRs for the next [MASKED] days. - Unable to switch to Apixiban at this time due to deductible of $416/month for first month - SBE prophylaxis x 6 mos post-procedure - Follow up TEE in 45 days; Follow up with NP [MASKED] # Embolic CVA: RUE weakness with +pronator drift and garbled speech, code stroke called, with CT and MRI results as above. Seen by acute [MASKED] while in patient with recommendation for acute rehab. - Appreciate neurology recommendations. - Keep HOB at 30 deg for aspiration precautions and to maximize cerebral perfusion - Allow BP to autoregulate - No need for stroke work up labs given that she was worked up recently and risk factors known; follow up with neurology as previously scheduled - Continue current anticoagulation regimen - Patient has now been seen by [MASKED], OT, S/S - Appreciate [MASKED] recommendations: acute rehab - Appreciate Speech and Swallow recommendations 1. Diet: NECTAR thick liquids, REGULAR solids 2. Medications: whole in puree 3. Aspiration precautions: - strict 1:1 assist - ensure SMALL bites/sips - ensure SLOW rate - cup sips only - no straws - reduce distractions: no talking, lights on, TV off, phone put away 4. TID oral care 5. If continued dysphonia, pt may benefit from further workup by ENT and may also benefit from voice therapy upon d/c as an outpatient/within home. # GI/Nutrition: - diet as above - Cardiac heart healthy diet once passes - Bowel regimen with Senna, MiraLax # Renal: Baseline Cr: 1.9, 1.6 today - Continue to trend # Psychiatric/Behavioral: mood stable - No active issues # DISPO: To [MASKED] Acute Rehab on [MASKED] # Transitional: [ ] Continue Warfarin for next [MASKED] days with weekly INRs [ ] TEE in 45 days as schedule; follow up with [MASKED] NP as scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. CARVedilol 3.125 mg PO BID 3. Warfarin 5.5 mg PO DAILY16 4. NIFEdipine (Extended Release) 60 mg PO DAILY 5. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 3. Atorvastatin 40 mg PO QPM 4. CARVedilol 3.125 mg PO BID 5. NIFEdipine (Extended Release) 60 mg PO DAILY 6. Warfarin 5.5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: - Subarachnoid hemorrhage [MASKED] s/p craniotomy and clip ligation - Paroxysmal Atrial Fibrillation on Warfarin with high risk for bleeding now s/p Watchman device - Periprocedural Embolic CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL & WHAT HAPPENDED IN THE HOSPITAL? =========================================================== - You had a Watchman device implanted to decrease the risk of stroke due to atrial fibrillation. - You developed right arm weakness after the procedure and an MRI of your head confirmed you had new areas of small strokes. - The weakness in your right arm and your difficulty with speech is much improved. - The Neurology team & the Physical and Occupational therapists agree that you will need acute rehab for continued work with speech, [MASKED] and OT. WHAT SHOULD I DO WHEN I GO HOME? ================================ -Take all of your medications as prescribed (listed below). -CONTINUE taking your Warfarin, for at least the next [MASKED] days and then otherwise directed by Dr. [MASKED]. You are currently taking 5.5mg once daily. Your INR 2.7 today. When you are discharged from rehab, [MASKED] Anticoagulation will continue to follow your INRs. -You should also continue to take Aspirin 81mg daily. - Activity restrictions and information related to care of the access sites in the groin are included in your discharge instructions. - You will need prophylactic antibiotics prior to any dental procedure for the next 6 months. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure including dental cleanings. - Follow up with your doctors as listed below It was a pleasure participating in your care. If you have any urgent questions that are related to your recovery from your hospitalization 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. -Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I480", "Z7901", "Y92230", "I129", "Z8673" ]
[ "I480: Paroxysmal atrial fibrillation", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "I97820: Postprocedural cerebrovascular infarction following cardiac surgery", "E854: Organ-limited amyloidosis", "N184: Chronic kidney disease, stage 4 (severe)", "M317: Microscopic polyangiitis", "Z7901: Long term (current) use of anticoagulants", "G8321: Monoplegia of upper limb affecting right dominant side", "R4789: Other speech disturbances", "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", "R29703: NIHSS score 3", "I680: Cerebral amyloid angiopathy", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I776: Arteritis, unspecified", "Z9114: Patient's other noncompliance with medication regimen" ]
10,051,043
26,563,181
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___: Diagnostic angiogram ___: Left craniotomy for clipping of left ICA bifurcation aneurysm History of Present Illness: ___ is a ___ female on ASA 81 (last taken ___ being worked up for CNS vasculitis and recent admission for embolic stroke secondary to a-fib who presents today for suspected aneurysmal SAH. Patient awoke with WHOL this morning at 3am. She denies having any neurologic symptoms, visual changes or ___ at this time. She called EMS who took her to ___ where a ___ showed diffuse left-sided SAH. She was transported to the ___ via life flight and Neurosurgery was consulted to evaluate and determine the need for surgical intervention. Past Medical History: Microscopic Polyangiitis Chronic Kidney Disease Paroxysmal Atrial Fibrillation Acute ischemic stroke (multiple) in ___ History of subacute stroke History of multifocal small vessel strokes Diffuse Alveolar Hemorrhage Suspected Lyme disease -Has been seen by a Lyme specialist and has been treated with multiple courses of Erythromycin/Tetracycline over ___ years Social History: ___ Family History: Patient does not believe there is a family history of aneurysms. Mother with unknown cancer. Physical Exam: ON ADMISSION: ============= ___ and ___: [ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity [x]Grade II: Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy. [ ]Grade III: Drowsiness/Confusion, mild focal neurological deficit. [ ]Grade IV: Stupor, moderate-severe hemiparesis. [ ]Grade V: Coma, decerebrate posturing. ___ Grade: [ ]1 No hemorrhage evident [ ]2 Subarachnoid hemorrhage less than 1mm thick [x]3 Subarachnoid hemorrhage more than 1mm thick [ ]4 Subarachnoid hemorrhage of any thickness with IVH or parenchymal extension WFNS SAH Grading Scale: [x]Grade I: GCS 15, no motor deficit [ ]Grade II: GCS ___, no motor deficit [ ]Grade III: GCS ___, with motor deficit [ ]Grade IV: GCS ___, with or without motor deficit [ ]Grade V: GCS ___, with or without motor deficit ___ Coma Scale: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands _15___ Total VS: HR 114; BP 142/72; RR 22; 100% RA Gen: No acute distress - complains of HA. Appears well. HEENT: Pupils: 3-2.5mm bilaterally, EOMs intact. Extremities: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative, 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: PERRL 3-2.5mm. Visual fields are full to confrontation. III, IV, VI: EOMI bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact. 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 ON DISCHARGE: ============= ___ ___ Temp: 97.5 PO BP: 143/93 L Sitting HR: 79 RR: 19 O2 sat: 98% O2 delivery: ra Exam: Sitting in bed, comfortable. Anxious and awaiting plan for discharge. Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious Orientation: [x] Person [x] Place [x] Time Follows commands: [ ] Simple [x] Complex [ ] None Pupils: PERRL (3mm to 2mm) EOM: [x] Full [ ] Restricted Face Symmetric: [x] No - Very slight left ptosis, left facial, activates symmetrically Tongue Midline: [x] Yes [ ] No Pronator Drift: [ ] Yes [x] No Speech Fluent: [x] Yes [ ] No Comprehension intact: [x] Yes [ ] No Motor: No drift. Moves all extremities symmetric, full strength throughout. Sensation: Grossly intact to light touch Wound: Clean, dry, intact Sutures removed today- wound well approximated, no signs of infection Pertinent Results: Please see OMR for pertinent lab results and imaging. Brief Hospital Course: #Subarachnoid hemorrhage On ___, Ms. ___ was admitted to the Neuro ICU with diffuse left-sided SAH. She was started on keppra, nimodipine and nicardipine. Diagnostic angiogram was initially negative for aneurysm. She was admitted to the stroke neurology service to evaluate for CNS vasculitis as etiology for hemorrhage. MRI brain w/w contrast was obtained revealing multiple lobar-distributed microhemorrhages suspicious of CAA and an acute left thalamic stroke. She was transferred to ___ on ___. LP was performed ___ and was revealing for elevated OP and elevated RBC's as well as HSV for which she was started of Acyclovir for a total course of 10 days. Repeat CTA on ___ revealed a 2mm aneurysm superior to left carotid terminus. She was transferred back to Neuro ICU and arterial line was placed for close blood pressure control. On ___, she was taken to the OR for elective clipping of left ICA aneurysm. postoperatively, she was noted to have new expressive aphasia. ___ revealed infarct in the left internal capsule and thalamus which were present on prior imaging. Speech improved during her ICU stay. Her mental status continued to improve, she continued her nimodipine for 21 days post SAH. ___ continue to express concerns for cognition and home safety and recommended home with 24h supervision. Social work was consulted. On ___, the patient was transferred to the floor. She completed her Dexamethasone taper. Left craniotomy site sutures were removed on ___ prior to discharge. #Dispo Patient had an argument with her healthcare proxy because she felt the HCProxy was sabotaging her discharge to go home independently. She discontinued communication with the health care proxy and named her daughter HCP. The patient's son and daughter are unable to provide 24h supervision upon discharge home. She has 2 sisters in ___, one is ___ old and unable to provide care while the other she has a turbulent relationship with per her daughter. Psychiatry was consulted for capacity evaluation and a team meeting was held to discuss a safe dispo plan. ___ and social work are in agreement that patient would be safe to go home with ___ services at home and frequent checks from family and friends. Patient's daughter to tentatively return to the ___ on ___ for work business and will stay with her mother. ___ re-evaluated patient on ___ and deemed the patient to have capacity to make her own medical decisions. The patient has agreed to discharge home with maximum services including ___ and social work has assisted the patient to set up elder services upon return home. The patient reports that her friend ___ has agreed that the patient can stay with her tonight after discharge. Patient's daughter has been in touch with case management and is aware of this current plan for discharge home with maximum services. #Hyponatremia On admission, the patient was hyponatremic to 129. She was bolused with normal saline and sodium normalized. She was again hyponatremic to 127 on ___ and started on hypertonic saline, this was eventually weaned and she remained stable on Salt tabs 1G PO TID. Plan to wean salt tabs to off after discharge and the patient will follow-up with PCP upon discharge. #Hyperkalemia The patient was noted to have intermittent hyperkalemia with K up to 5.8 on morning of discharge. Subsequent lab draw in ___ was 5.1. The patient was encouraged to increase PO intake and she will follow-up with her PCP as an outpatient for further monitoring and management. #Fever The patient was febrile on ___ and pancultured. CXR was concerning for infection vs underlying airway disease. HSV PCR was positive and she was started on acyclovir on ___ with end date of ___. Further work up revealed UTI and she was started on MacroBID which was completed on ___. AHA/ASA Core Measures for ICH: 1. Dysphagia screening before any PO intake? [x]Yes []No 2. DVT prophylaxis administered? [x]Yes []No 3. Smoking cessation counseling given? []Yes [x]No [Reason: (x)non-smoker ()unable to participate] 4. Stroke Education given in written form? [x]Yes []No 5. Assessment for rehabilitation and/or rehab services considered? []Yes [x]No -> at baseline functional status. Stroke Measures: 1. Was ___ performed within 6hrs of arrival? [x]Yes []No 2. Was a Procoagulant Reversal agent given? []Yes [x]No [Reason: Stable, small SAH] 3. Was Nimodipine given? [x]Yes []No [Reason:] Medications on Admission: Aspirin 81mg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 2. NiMODipine 60 mg PO Q4H RX *nimodipine 30 mg 2 (Two) capsule(s) by mouth every four (4) hours Disp #*16 Capsule Refills:*0 3. Sodium Chloride 1 gm PO BID RX *sodium chloride 1 gram 1 tablet(s) by mouth BID x2 days then QD x2 days Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage Left ICA bifurcation aneurysm HSV-2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were hospitalized due to symptoms of headache resulting from a subarachnoid hemorrhage. This is a condition caused by a leakage of blood within the brain. While you were here in the hospital, you had an angiogram to look for an aneurysm. Fortunately this showed no evidence of hemorrhage. You also had a lumbar puncture. This showed HSV and you were started on Acyclovir for a total course of 10 days. Please take your 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 Aneurysmal Subarachnoid Hemorrhage • Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). What You ___ Experience: •Mild to moderate headaches that last several days to a few weeks. •Difficulty with short term memory. •Fatigue is very normal When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site or puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg 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 While you were hospitalized an additional CTA was performed revealing a new 2mm left ICA bifurcation aneurysm for which you underwent a left craniotomy for clipping treatment of your aneurysm. Discharge Instructions for: Elective Aneurysm Clipping Call your neurosurgeon’s office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Swelling, drainage, or redness of your incision - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate – but start slowly and increase at your own pace. -Do not operate any motorized vehicle for at least 10 days after your surgery – your Nurse Practitioner can give you more detail at the time of your suture removal. Your sutures will be removed prior to discharge. Incision Care: - Keep your wound clean and dry. - Do not use shampoo until your sutures are removed. - When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. - Do not rub, scrub, scratch, or pick at any scabs on the incision line. - You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical - Jaw pain on the same side as your surgery; this goes away after about a month - You may experience constipation. Constipation can be prevented by: o Drinking plenty of fluids o Increasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements o Exercising o Using over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea - Fatigue which will slowly resolve over time - Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve - Muffled hearing in the ear near the incision area - Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional - You may experience depression. Symptoms of depression can include o Feeling “down” or sad o Irritability, frustration, and confusion o Distractibility o Lower Self-Esteem/Relationship Challenges o Insomnia o Loneliness - If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist - You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation o More information can be found at ___ Followup Instructions: ___
[ "I6002", "N390", "E871", "M317", "R4701", "R471", "Z8673", "T45526A", "Z91120", "Y929", "E8351", "I129", "N189", "I480", "R402142", "R402252", "R402362", "Z9114", "H9319", "T45516A", "Z91128", "B009", "I951", "B9620", "F329", "F4321", "Z6379", "Z598", "E875" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Headache Major Surgical or Invasive Procedure: [MASKED]: Diagnostic angiogram [MASKED]: Left craniotomy for clipping of left ICA bifurcation aneurysm History of Present Illness: [MASKED] is a [MASKED] female on ASA 81 (last taken [MASKED] being worked up for CNS vasculitis and recent admission for embolic stroke secondary to a-fib who presents today for suspected aneurysmal SAH. Patient awoke with WHOL this morning at 3am. She denies having any neurologic symptoms, visual changes or [MASKED] at this time. She called EMS who took her to [MASKED] where a [MASKED] showed diffuse left-sided SAH. She was transported to the [MASKED] via life flight and Neurosurgery was consulted to evaluate and determine the need for surgical intervention. Past Medical History: Microscopic Polyangiitis Chronic Kidney Disease Paroxysmal Atrial Fibrillation Acute ischemic stroke (multiple) in [MASKED] History of subacute stroke History of multifocal small vessel strokes Diffuse Alveolar Hemorrhage Suspected Lyme disease -Has been seen by a Lyme specialist and has been treated with multiple courses of Erythromycin/Tetracycline over [MASKED] years Social History: [MASKED] Family History: Patient does not believe there is a family history of aneurysms. Mother with unknown cancer. Physical Exam: ON ADMISSION: ============= [MASKED] and [MASKED]: [ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity [x]Grade II: Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy. [ ]Grade III: Drowsiness/Confusion, mild focal neurological deficit. [ ]Grade IV: Stupor, moderate-severe hemiparesis. [ ]Grade V: Coma, decerebrate posturing. [MASKED] Grade: [ ]1 No hemorrhage evident [ ]2 Subarachnoid hemorrhage less than 1mm thick [x]3 Subarachnoid hemorrhage more than 1mm thick [ ]4 Subarachnoid hemorrhage of any thickness with IVH or parenchymal extension WFNS SAH Grading Scale: [x]Grade I: GCS 15, no motor deficit [ ]Grade II: GCS [MASKED], no motor deficit [ ]Grade III: GCS [MASKED], with motor deficit [ ]Grade IV: GCS [MASKED], with or without motor deficit [ ]Grade V: GCS [MASKED], with or without motor deficit [MASKED] Coma Scale: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ [MASKED] Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands 15 Total VS: HR 114; BP 142/72; RR 22; 100% RA Gen: No acute distress - complains of HA. Appears well. HEENT: Pupils: 3-2.5mm bilaterally, EOMs intact. Extremities: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative, 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: PERRL 3-2.5mm. Visual fields are full to confrontation. III, IV, VI: EOMI bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact. 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 ON DISCHARGE: ============= [MASKED] [MASKED] Temp: 97.5 PO BP: 143/93 L Sitting HR: 79 RR: 19 O2 sat: 98% O2 delivery: ra Exam: Sitting in bed, comfortable. Anxious and awaiting plan for discharge. Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious Orientation: [x] Person [x] Place [x] Time Follows commands: [ ] Simple [x] Complex [ ] None Pupils: PERRL (3mm to 2mm) EOM: [x] Full [ ] Restricted Face Symmetric: [x] No - Very slight left ptosis, left facial, activates symmetrically Tongue Midline: [x] Yes [ ] No Pronator Drift: [ ] Yes [x] No Speech Fluent: [x] Yes [ ] No Comprehension intact: [x] Yes [ ] No Motor: No drift. Moves all extremities symmetric, full strength throughout. Sensation: Grossly intact to light touch Wound: Clean, dry, intact Sutures removed today- wound well approximated, no signs of infection Pertinent Results: Please see OMR for pertinent lab results and imaging. Brief Hospital Course: #Subarachnoid hemorrhage On [MASKED], Ms. [MASKED] was admitted to the Neuro ICU with diffuse left-sided SAH. She was started on keppra, nimodipine and nicardipine. Diagnostic angiogram was initially negative for aneurysm. She was admitted to the stroke neurology service to evaluate for CNS vasculitis as etiology for hemorrhage. MRI brain w/w contrast was obtained revealing multiple lobar-distributed microhemorrhages suspicious of CAA and an acute left thalamic stroke. She was transferred to [MASKED] on [MASKED]. LP was performed [MASKED] and was revealing for elevated OP and elevated RBC's as well as HSV for which she was started of Acyclovir for a total course of 10 days. Repeat CTA on [MASKED] revealed a 2mm aneurysm superior to left carotid terminus. She was transferred back to Neuro ICU and arterial line was placed for close blood pressure control. On [MASKED], she was taken to the OR for elective clipping of left ICA aneurysm. postoperatively, she was noted to have new expressive aphasia. [MASKED] revealed infarct in the left internal capsule and thalamus which were present on prior imaging. Speech improved during her ICU stay. Her mental status continued to improve, she continued her nimodipine for 21 days post SAH. [MASKED] continue to express concerns for cognition and home safety and recommended home with 24h supervision. Social work was consulted. On [MASKED], the patient was transferred to the floor. She completed her Dexamethasone taper. Left craniotomy site sutures were removed on [MASKED] prior to discharge. #Dispo Patient had an argument with her healthcare proxy because she felt the HCProxy was sabotaging her discharge to go home independently. She discontinued communication with the health care proxy and named her daughter HCP. The patient's son and daughter are unable to provide 24h supervision upon discharge home. She has 2 sisters in [MASKED], one is [MASKED] old and unable to provide care while the other she has a turbulent relationship with per her daughter. Psychiatry was consulted for capacity evaluation and a team meeting was held to discuss a safe dispo plan. [MASKED] and social work are in agreement that patient would be safe to go home with [MASKED] services at home and frequent checks from family and friends. Patient's daughter to tentatively return to the [MASKED] on [MASKED] for work business and will stay with her mother. [MASKED] re-evaluated patient on [MASKED] and deemed the patient to have capacity to make her own medical decisions. The patient has agreed to discharge home with maximum services including [MASKED] and social work has assisted the patient to set up elder services upon return home. The patient reports that her friend [MASKED] has agreed that the patient can stay with her tonight after discharge. Patient's daughter has been in touch with case management and is aware of this current plan for discharge home with maximum services. #Hyponatremia On admission, the patient was hyponatremic to 129. She was bolused with normal saline and sodium normalized. She was again hyponatremic to 127 on [MASKED] and started on hypertonic saline, this was eventually weaned and she remained stable on Salt tabs 1G PO TID. Plan to wean salt tabs to off after discharge and the patient will follow-up with PCP upon discharge. #Hyperkalemia The patient was noted to have intermittent hyperkalemia with K up to 5.8 on morning of discharge. Subsequent lab draw in [MASKED] was 5.1. The patient was encouraged to increase PO intake and she will follow-up with her PCP as an outpatient for further monitoring and management. #Fever The patient was febrile on [MASKED] and pancultured. CXR was concerning for infection vs underlying airway disease. HSV PCR was positive and she was started on acyclovir on [MASKED] with end date of [MASKED]. Further work up revealed UTI and she was started on MacroBID which was completed on [MASKED]. AHA/ASA Core Measures for ICH: 1. Dysphagia screening before any PO intake? [x]Yes []No 2. DVT prophylaxis administered? [x]Yes []No 3. Smoking cessation counseling given? []Yes [x]No [Reason: (x)non-smoker ()unable to participate] 4. Stroke Education given in written form? [x]Yes []No 5. Assessment for rehabilitation and/or rehab services considered? []Yes [x]No -> at baseline functional status. Stroke Measures: 1. Was [MASKED] performed within 6hrs of arrival? [x]Yes []No 2. Was a Procoagulant Reversal agent given? []Yes [x]No [Reason: Stable, small SAH] 3. Was Nimodipine given? [x]Yes []No [Reason:] Medications on Admission: Aspirin 81mg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 2. NiMODipine 60 mg PO Q4H RX *nimodipine 30 mg 2 (Two) capsule(s) by mouth every four (4) hours Disp #*16 Capsule Refills:*0 3. Sodium Chloride 1 gm PO BID RX *sodium chloride 1 gram 1 tablet(s) by mouth BID x2 days then QD x2 days Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Subarachnoid hemorrhage Left ICA bifurcation aneurysm HSV-2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were hospitalized due to symptoms of headache resulting from a subarachnoid hemorrhage. This is a condition caused by a leakage of blood within the brain. While you were here in the hospital, you had an angiogram to look for an aneurysm. Fortunately this showed no evidence of hemorrhage. You also had a lumbar puncture. This showed HSV and you were started on Acyclovir for a total course of 10 days. Please take your 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 Aneurysmal Subarachnoid Hemorrhage • Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). What You [MASKED] Experience: •Mild to moderate headaches that last several days to a few weeks. •Difficulty with short term memory. •Fatigue is very normal When to Call Your Doctor at [MASKED] for: •Severe pain, swelling, redness or drainage from the incision site or puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg 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 While you were hospitalized an additional CTA was performed revealing a new 2mm left ICA bifurcation aneurysm for which you underwent a left craniotomy for clipping treatment of your aneurysm. Discharge Instructions for: Elective Aneurysm Clipping Call your neurosurgeon’s office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Swelling, drainage, or redness of your incision - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate – but start slowly and increase at your own pace. -Do not operate any motorized vehicle for at least 10 days after your surgery – your Nurse Practitioner can give you more detail at the time of your suture removal. Your sutures will be removed prior to discharge. Incision Care: - Keep your wound clean and dry. - Do not use shampoo until your sutures are removed. - When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. - Do not rub, scrub, scratch, or pick at any scabs on the incision line. - You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical - Jaw pain on the same side as your surgery; this goes away after about a month - You may experience constipation. Constipation can be prevented by: o Drinking plenty of fluids o Increasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements o Exercising o Using over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea - Fatigue which will slowly resolve over time - Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve - Muffled hearing in the ear near the incision area - Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional - You may experience depression. Symptoms of depression can include o Feeling “down” or sad o Irritability, frustration, and confusion o Distractibility o Lower Self-Esteem/Relationship Challenges o Insomnia o Loneliness - If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist - You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation o More information can be found at [MASKED] Followup Instructions: [MASKED]
[]
[ "N390", "E871", "Z8673", "Y929", "I129", "N189", "I480", "F329" ]
[ "I6002: Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "M317: Microscopic polyangiitis", "R4701: Aphasia", "R471: Dysarthria and anarthria", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "T45526A: Underdosing of antithrombotic drugs, initial encounter", "Z91120: Patient's intentional underdosing of medication regimen due to financial hardship", "Y929: Unspecified place or not applicable", "E8351: Hypocalcemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I480: Paroxysmal atrial fibrillation", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "Z9114: Patient's other noncompliance with medication regimen", "H9319: Tinnitus, unspecified ear", "T45516A: Underdosing of anticoagulants, initial encounter", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "B009: Herpesviral infection, unspecified", "I951: Orthostatic hypotension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F329: Major depressive disorder, single episode, unspecified", "F4321: Adjustment disorder with depressed mood", "Z6379: Other stressful life events affecting family and household", "Z598: Other problems related to housing and economic circumstances", "E875: Hyperkalemia" ]
10,051,043
26,948,064
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dizziness, blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH of microscopic polyangiitis diagnosed in ___, multiple episodes of ischemic stroke in ___, paroxysmal atrial fibrillation S/P watchman device placement ___ who presented as a direct admission from ___ for vasculitis work-up. Patient initially presented to ___ on ___ with dizziness starting 2 AM on ___ while she was in the day room at ___. At the time, she had nausea, double vision. She went back to bed at 5 AM and slept for a while. When she woke up for breakfast, she felt dizzy, and her gait was unsteady. She fell to the ground and struck her head but did not lose consciousness. She was brought to ___, where she was vomiting. CT head showed multiple chronic bilateral basal ganglia and corona radiata infarcts, but no acute infarct. Patient was seen by Dr. ___ on ___, where she reported double vision with vertical images. Upon arrival to ___, patient reported lightheadedness and blurred vision. She states that she previously had double vision with vertical images, but now her vision is blurred, sometimes improved by closing one eye but not always. She denies nausea. Per Dr. ___ note, she had an ischemic stroke in ___ of the anterior limb of the left internal capsule. She was initially started on aspirin, which was stopped after PAH in ___. In ___, she had acute infarct of the right putamen, right corona radiata, left inferior caudate. A. fib was found and she was placed on apixaban, although she was noncompliant. In ___ she had acute infarcts of the left midbrain and anterior limb of the left internal capsule. In ___, she had diffuse bilateral subarachnoid hemorrhage. CTA showed 2 mm aneurysm of the left terminal ICA. She underwent craniotomy and clipping of this aneurysm. In ___, she had acute right posterior periventricular and right frontal subcortical infarcts. She was supposed to be taking a apixaban but she was noncompliant. During the admission, Lovenox was given as a bridge to warfarin. In ___, she had watchman device placement. She then had multiple small acute infarcts in the bilateral centrum semi-ovale and corona radiata, as well as a pontine infarct. She was discharged on warfarin 5.5 mg daily and aspirin 81. In late ___, she had 2 left frontal infarcts and a right cerebellar infarct of varying ages. In ___, her warfarin was stopped as a TEE in ___ showed no thrombus in the left atrium or atrial appendage. The plan was for aspirin 81 daily indefinitely with repeat TEE at 6 months in ___ year. Past Medical History: Microscopic polyangiitis with lung and renal involvement (stage 4 CKD), not on treatment currently as previously refused and recently felt to be quiescent by rheum -AF s/p Watchman device (anticoagulation ___, previously non-compliant) -ischemic strokes x5-6 since ___, most recently ___ which prompted ___ -___ ___ s/p aneurysm clipping -?Amyloid angiopathy (innumerable cerebral microhemorrhages on MRI) -pulmonary MAC infection discovered in ___, patient declined treatment -severe large fibre sensorimotor polyneuropathy (not sure if attributable to vasculitis, unclear if advanced mononeuritis multiplex vs. length-dependent process) Social History: ___ Family History: Mother had cancer of unknown type. She has a son and a daughter. She has been living at ___ for several months. She states that she had been hoping for discharge from the facility. Physical Exam: ADMISSION PHYSCIAL EXAM ========================= General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: Normal work of breathing. Cardiac: 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. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name chair, hammock, key, glove, but not cactus or feather. Able to read. No dysarthria. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild L NLFF VIII: Hearing intact to conversation. 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. [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, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 3 3 2 R 2 2 3 3 2 R toe mute. L toe upgoing -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. however, patient does have slowed finger tapping on the left -Gait: Deferred DISCHARGE PHYSICAL EXAM ========================= Temp: 98.3 (Tm 98.5), BP: 165/96 (128-184/76-96), HR: 68 (65-74), RR: 18, O2 sat: 94% (92-97), O2 delivery: RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: Normal work of breathing. Cardiac: Warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, no confabulation this morning. Oriented to place. States month is ___. Mild hoarseness improved from yesterday. Still w/ some dysarthria. Language is fluent with intact repetition and comprehension. No prosody. No paraphasic errors. Still effortful to get through MOYB -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. Slight right hypertropia w/ intact EOM. No clear double vision, though does note her vision is "off" on primary gaze. V: Facial sensation intact to light touch. VII: Mild L NLFF VIII: Hearing intact to finger rub. 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. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 ___- 5 5 5 5 5 R 5 5 5 5 4+ 5- 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 3 3 2 R 2 2 3 3 2 -Coordination: Dysmetria with overshoot and past-pointing on mirroring on left. Slower rapid movements of left hand compared to right. Slight ataxia on heel-to-shin on left. -Gait: Deferred Pertinent Results: LABS ===== ___ 11:52PM BLOOD WBC-10.0 RBC-3.95 Hgb-10.6* Hct-33.6* MCV-85 MCH-26.8 MCHC-31.5* RDW-15.2 RDWSD-47.0* Plt ___ ___ 08:44AM BLOOD WBC-8.0 RBC-3.56* Hgb-9.6* Hct-30.5* MCV-86 MCH-27.0 MCHC-31.5* RDW-14.9 RDWSD-47.0* Plt ___ ___ 11:52PM BLOOD Glucose-100 UreaN-20 Creat-1.4* Na-135 K-4.5 Cl-97 HCO3-25 AnGap-13 ___ 08:44AM BLOOD Glucose-108* UreaN-25* Creat-1.4* Na-135 K-4.2 Cl-99 HCO3-21* AnGap-15 ___ 05:58AM BLOOD ALT-11 AST-11 AlkPhos-202* TotBili-0.3 ___ 11:52PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 ___ 05:58AM BLOOD %HbA1c-5.5 eAG-111 ___ 05:58AM BLOOD Triglyc-79 HDL-54 CHOL/HD-2.1 LDLcalc-46 ___ 11:52AM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-4 Polys-7 ___ Macroph-3 ___ 11:52AM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-65 PENDING LABS ============= ___ 05:58AM BLOOD Trep Ab-PND ___ 08:41AM BLOOD Smooth-PND ___ 08:41AM BLOOD SM ANTIBODY-PND ___ 08:41AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND ___ 11:52AM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-PND IMAGING ========= IMPRESSION: 1. No interval change compared to MRI from 2 days ago. No evidence of pachymeningeal enhancement. 2. Left cerebellar hemisphere and right parietal white matter subacute infarctions appear unchanged.. 3. Chronic lacunar infarct in changes of chronic microangiopathy in the white matter. 4. Unchanged multiple micro bleeds in a distribution most suggestive of amyloid angiopathy. 5. Unchanged postoperative findings after left craniotomy and aneurysm clipping. Brief Hospital Course: Summary ========= ___ with PMH of microscopic polyangiitis diagnosed in ___, inumerable episodes of ischemic stroke from ___, paroxysmal atrial fibrillation S/P Watchman placement ___ who presented as a direct admission from ___ for vasculitis work-up after initially presenting with dizziness, nausea, diplopia. MRI brain at ___ showed acute infarct of the left paramedian ___ cerebellum and subacute infarct right parietal corona radiata. Transitional Issues ===================== [ ] Pt had a dermatology biopsy ___ of a few areas of her abdomen. She had sutures placed and those will need to be removed (by nursing or a physicians at her facility) on or around ___ (two weeks following the biopsy ) [ ] Please consider transition from Aspirin 81mg to Plavix 75mg given recurrent stroke on aspirin [ ] Multiple labs pending at the time of discharge including: treponemal ab, anti-cardiolipin antibodies, antiSM antibodies, pathology from skin biopsies, MS panel [ ] Follow-up blood pressures, amlodipine was started this admission for hypertension [ ] CSF hold was done if there is a need for further CSF studies [ ] Pt ntoed to have a normocytic anemia on presentation, please ensure patient has had adequate workup w/ age appropriate cancer screenings (ie. colonscopy) [ ] Please ensure that patient has a primary care appointment scheduled with her PCP ___ ischemic infarcts In the past her strokes have largely been attributed to cardioembolic infarcts iso non-compliance on AC, however it seems unlikely that pt has had several strokes since ___ from a cardioembolic source w/ a watchman present when there is no thrombus present. ___ was repeated this admission and did not show any Watchman associated thrombus. Additionally she had TCDs done to evaluate for possible ongoing microthrombi which were largely unremarkable. Differential at this time still includes recurrent cardioembolic emboli from atypical atrial cardiopathy (though very atypical that pt has only had subcortical infarcts). Pt has undergone extensive workup in the past for etiology of her strokes including a hypercoaguable workup, she had a recent conventional angiogram iso her SAH, which did not show evidence of a vasculitis. At this point pt does not have active evidence of inflammation or systemic vasculitis -- she had a mildly elevated ESR ~ 50, but a normal CRP, no new pulmonary symptoms, her Cr was close to her baseline and did not reveal a very active urinary sediment (pr/cr borderline elevated at .9). Rheumatology was consulted who overall did not believe her presentation was consistent w/ either as systemic or CNS vasculitis. Additionally we repeated an LP which yielded a bland CSF (TNC 1, RBC 4, Protein 28, glu 65). We repeated an MRI w/ MPRAGE sequences here which did not show evidence of vasculitis. The differential for etiology of his strokes given largely subcortical distribution, included intravascular lymphoma for which a skin biopsy was pursued, results of which were pending at discharge. Additionally, CADASIL was considered given subcortical distribution of infarcts (including a temporal lobe infarct that is in a somewhat atypical location for normal small vessel disease), as well as her underlying cognitive deficits, however notably the patient does not have migraine or a family hx of strokes. Given the diagnostic uncertainty, a brain biopsy was carefully considered, but after discussions with the patient, this was deferred due to patient preference and relatively low yield of the test. Management of her recurrent strokes is difficult given her hx of SAH and probable CAA w/ evidence of microbleeds. At this time she was discharged on Aspirin 81mg and atorvastatin 40mg, though switching from aspirin to Plavix 75mg given recurrent strokes of unclear etiology could be a consideration in the future. #HTN Continued home carvedilol 3.125 mg BID at home. Resumed home nifedipine. #Hx of microscopic polyangiitis #MAC Has been off immunosuppression without significant recurrence. Notably, has a hx of MAC colonization so would need treatment prior to further immunosuppression. Pt was evaluated by rheumatology while inpatient 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 =46 ) - () 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 [ ] 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? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - If no, why not (I.e. bleeding risk, etc.) -- high bleeding risk w/ hx of ___, CAA, has a watchman device in place () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. Atorvastatin 40 mg PO QPM 3. CARVedilol 3.125 mg PO BID 4. Aspirin 81 mg PO DAILY 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. CARVedilol 3.125 mg PO BID 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis =================== Acute Ischemic Stroke Secondary Diagnosis ==================== Hypertension Microscopic Polyangitis 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 unsteadiness 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 atrial fibrillation . We did a number of tests to look for evidence of inflammation, vasculitis, or other causes of your stroke. You had an echocardiogram, multiple MRIs and a lumbar puncture of spinal tap. You were also seen by the dermatology and rheumatology teams. There were some labs still pending at the time you were discharged back to rehab and Dr. ___ will follow these. We are changing your medications as follows: - Added Amlodipine for blood pressure 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: ___
[ "I63542", "M317", "N184", "E854", "I680", "I6389", "R42", "R2689", "H532", "R419", "I480", "I10", "R29701", "I671", "D649", "Z23", "Z8673", "Z2239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dizziness, blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMH of microscopic polyangiitis diagnosed in [MASKED], multiple episodes of ischemic stroke in [MASKED], paroxysmal atrial fibrillation S/P watchman device placement [MASKED] who presented as a direct admission from [MASKED] for vasculitis work-up. Patient initially presented to [MASKED] on [MASKED] with dizziness starting 2 AM on [MASKED] while she was in the day room at [MASKED]. At the time, she had nausea, double vision. She went back to bed at 5 AM and slept for a while. When she woke up for breakfast, she felt dizzy, and her gait was unsteady. She fell to the ground and struck her head but did not lose consciousness. She was brought to [MASKED], where she was vomiting. CT head showed multiple chronic bilateral basal ganglia and corona radiata infarcts, but no acute infarct. Patient was seen by Dr. [MASKED] on [MASKED], where she reported double vision with vertical images. Upon arrival to [MASKED], patient reported lightheadedness and blurred vision. She states that she previously had double vision with vertical images, but now her vision is blurred, sometimes improved by closing one eye but not always. She denies nausea. Per Dr. [MASKED] note, she had an ischemic stroke in [MASKED] of the anterior limb of the left internal capsule. She was initially started on aspirin, which was stopped after PAH in [MASKED]. In [MASKED], she had acute infarct of the right putamen, right corona radiata, left inferior caudate. A. fib was found and she was placed on apixaban, although she was noncompliant. In [MASKED] she had acute infarcts of the left midbrain and anterior limb of the left internal capsule. In [MASKED], she had diffuse bilateral subarachnoid hemorrhage. CTA showed 2 mm aneurysm of the left terminal ICA. She underwent craniotomy and clipping of this aneurysm. In [MASKED], she had acute right posterior periventricular and right frontal subcortical infarcts. She was supposed to be taking a apixaban but she was noncompliant. During the admission, Lovenox was given as a bridge to warfarin. In [MASKED], she had watchman device placement. She then had multiple small acute infarcts in the bilateral centrum semi-ovale and corona radiata, as well as a pontine infarct. She was discharged on warfarin 5.5 mg daily and aspirin 81. In late [MASKED], she had 2 left frontal infarcts and a right cerebellar infarct of varying ages. In [MASKED], her warfarin was stopped as a TEE in [MASKED] showed no thrombus in the left atrium or atrial appendage. The plan was for aspirin 81 daily indefinitely with repeat TEE at 6 months in [MASKED] year. Past Medical History: Microscopic polyangiitis with lung and renal involvement (stage 4 CKD), not on treatment currently as previously refused and recently felt to be quiescent by rheum -AF s/p Watchman device (anticoagulation [MASKED], previously non-compliant) -ischemic strokes x5-6 since [MASKED], most recently [MASKED] which prompted [MASKED] -[MASKED] [MASKED] s/p aneurysm clipping -?Amyloid angiopathy (innumerable cerebral microhemorrhages on MRI) -pulmonary MAC infection discovered in [MASKED], patient declined treatment -severe large fibre sensorimotor polyneuropathy (not sure if attributable to vasculitis, unclear if advanced mononeuritis multiplex vs. length-dependent process) Social History: [MASKED] Family History: Mother had cancer of unknown type. She has a son and a daughter. She has been living at [MASKED] for several months. She states that she had been hoping for discharge from the facility. Physical Exam: ADMISSION PHYSCIAL EXAM ========================= General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: Normal work of breathing. Cardiac: 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. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name chair, hammock, key, glove, but not cactus or feather. Able to read. No dysarthria. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild L NLFF VIII: Hearing intact to conversation. 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. [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, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [[MASKED]] [Pat] [Ach] L 2 2 3 3 2 R 2 2 3 3 2 R toe mute. L toe upgoing -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. however, patient does have slowed finger tapping on the left -Gait: Deferred DISCHARGE PHYSICAL EXAM ========================= Temp: 98.3 (Tm 98.5), BP: 165/96 (128-184/76-96), HR: 68 (65-74), RR: 18, O2 sat: 94% (92-97), O2 delivery: RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: Normal work of breathing. Cardiac: Warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, no confabulation this morning. Oriented to place. States month is [MASKED]. Mild hoarseness improved from yesterday. Still w/ some dysarthria. Language is fluent with intact repetition and comprehension. No prosody. No paraphasic errors. Still effortful to get through MOYB -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. Slight right hypertropia w/ intact EOM. No clear double vision, though does note her vision is "off" on primary gaze. V: Facial sensation intact to light touch. VII: Mild L NLFF VIII: Hearing intact to finger rub. 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. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 [MASKED]- 5 5 5 5 5 R 5 5 5 5 4+ 5- 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [[MASKED]] [Pat] [Ach] L 2 2 3 3 2 R 2 2 3 3 2 -Coordination: Dysmetria with overshoot and past-pointing on mirroring on left. Slower rapid movements of left hand compared to right. Slight ataxia on heel-to-shin on left. -Gait: Deferred Pertinent Results: LABS ===== [MASKED] 11:52PM BLOOD WBC-10.0 RBC-3.95 Hgb-10.6* Hct-33.6* MCV-85 MCH-26.8 MCHC-31.5* RDW-15.2 RDWSD-47.0* Plt [MASKED] [MASKED] 08:44AM BLOOD WBC-8.0 RBC-3.56* Hgb-9.6* Hct-30.5* MCV-86 MCH-27.0 MCHC-31.5* RDW-14.9 RDWSD-47.0* Plt [MASKED] [MASKED] 11:52PM BLOOD Glucose-100 UreaN-20 Creat-1.4* Na-135 K-4.5 Cl-97 HCO3-25 AnGap-13 [MASKED] 08:44AM BLOOD Glucose-108* UreaN-25* Creat-1.4* Na-135 K-4.2 Cl-99 HCO3-21* AnGap-15 [MASKED] 05:58AM BLOOD ALT-11 AST-11 AlkPhos-202* TotBili-0.3 [MASKED] 11:52PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 [MASKED] 05:58AM BLOOD %HbA1c-5.5 eAG-111 [MASKED] 05:58AM BLOOD Triglyc-79 HDL-54 CHOL/HD-2.1 LDLcalc-46 [MASKED] 11:52AM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-4 Polys-7 [MASKED] Macroph-3 [MASKED] 11:52AM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-65 PENDING LABS ============= [MASKED] 05:58AM BLOOD Trep Ab-PND [MASKED] 08:41AM BLOOD Smooth-PND [MASKED] 08:41AM BLOOD SM ANTIBODY-PND [MASKED] 08:41AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND [MASKED] 11:52AM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-PND IMAGING ========= IMPRESSION: 1. No interval change compared to MRI from 2 days ago. No evidence of pachymeningeal enhancement. 2. Left cerebellar hemisphere and right parietal white matter subacute infarctions appear unchanged.. 3. Chronic lacunar infarct in changes of chronic microangiopathy in the white matter. 4. Unchanged multiple micro bleeds in a distribution most suggestive of amyloid angiopathy. 5. Unchanged postoperative findings after left craniotomy and aneurysm clipping. Brief Hospital Course: Summary ========= [MASKED] with PMH of microscopic polyangiitis diagnosed in [MASKED], inumerable episodes of ischemic stroke from [MASKED], paroxysmal atrial fibrillation S/P Watchman placement [MASKED] who presented as a direct admission from [MASKED] for vasculitis work-up after initially presenting with dizziness, nausea, diplopia. MRI brain at [MASKED] showed acute infarct of the left paramedian [MASKED] cerebellum and subacute infarct right parietal corona radiata. Transitional Issues ===================== [ ] Pt had a dermatology biopsy [MASKED] of a few areas of her abdomen. She had sutures placed and those will need to be removed (by nursing or a physicians at her facility) on or around [MASKED] (two weeks following the biopsy ) [ ] Please consider transition from Aspirin 81mg to Plavix 75mg given recurrent stroke on aspirin [ ] Multiple labs pending at the time of discharge including: treponemal ab, anti-cardiolipin antibodies, antiSM antibodies, pathology from skin biopsies, MS panel [ ] Follow-up blood pressures, amlodipine was started this admission for hypertension [ ] CSF hold was done if there is a need for further CSF studies [ ] Pt ntoed to have a normocytic anemia on presentation, please ensure patient has had adequate workup w/ age appropriate cancer screenings (ie. colonscopy) [ ] Please ensure that patient has a primary care appointment scheduled with her PCP [MASKED] ischemic infarcts In the past her strokes have largely been attributed to cardioembolic infarcts iso non-compliance on AC, however it seems unlikely that pt has had several strokes since [MASKED] from a cardioembolic source w/ a watchman present when there is no thrombus present. [MASKED] was repeated this admission and did not show any Watchman associated thrombus. Additionally she had TCDs done to evaluate for possible ongoing microthrombi which were largely unremarkable. Differential at this time still includes recurrent cardioembolic emboli from atypical atrial cardiopathy (though very atypical that pt has only had subcortical infarcts). Pt has undergone extensive workup in the past for etiology of her strokes including a hypercoaguable workup, she had a recent conventional angiogram iso her SAH, which did not show evidence of a vasculitis. At this point pt does not have active evidence of inflammation or systemic vasculitis -- she had a mildly elevated ESR ~ 50, but a normal CRP, no new pulmonary symptoms, her Cr was close to her baseline and did not reveal a very active urinary sediment (pr/cr borderline elevated at .9). Rheumatology was consulted who overall did not believe her presentation was consistent w/ either as systemic or CNS vasculitis. Additionally we repeated an LP which yielded a bland CSF (TNC 1, RBC 4, Protein 28, glu 65). We repeated an MRI w/ MPRAGE sequences here which did not show evidence of vasculitis. The differential for etiology of his strokes given largely subcortical distribution, included intravascular lymphoma for which a skin biopsy was pursued, results of which were pending at discharge. Additionally, CADASIL was considered given subcortical distribution of infarcts (including a temporal lobe infarct that is in a somewhat atypical location for normal small vessel disease), as well as her underlying cognitive deficits, however notably the patient does not have migraine or a family hx of strokes. Given the diagnostic uncertainty, a brain biopsy was carefully considered, but after discussions with the patient, this was deferred due to patient preference and relatively low yield of the test. Management of her recurrent strokes is difficult given her hx of SAH and probable CAA w/ evidence of microbleeds. At this time she was discharged on Aspirin 81mg and atorvastatin 40mg, though switching from aspirin to Plavix 75mg given recurrent strokes of unclear etiology could be a consideration in the future. #HTN Continued home carvedilol 3.125 mg BID at home. Resumed home nifedipine. #Hx of microscopic polyangiitis #MAC Has been off immunosuppression without significant recurrence. Notably, has a hx of MAC colonization so would need treatment prior to further immunosuppression. Pt was evaluated by rheumatology while inpatient 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 =46 ) - () 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 [ ] 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? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - If no, why not (I.e. bleeding risk, etc.) -- high bleeding risk w/ hx of [MASKED], CAA, has a watchman device in place () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. Atorvastatin 40 mg PO QPM 3. CARVedilol 3.125 mg PO BID 4. Aspirin 81 mg PO DAILY 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. CARVedilol 3.125 mg PO BID 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Primary Diagnosis =================== Acute Ischemic Stroke Secondary Diagnosis ==================== Hypertension Microscopic Polyangitis 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 unsteadiness 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 atrial fibrillation . We did a number of tests to look for evidence of inflammation, vasculitis, or other causes of your stroke. You had an echocardiogram, multiple MRIs and a lumbar puncture of spinal tap. You were also seen by the dermatology and rheumatology teams. There were some labs still pending at the time you were discharged back to rehab and Dr. [MASKED] will follow these. We are changing your medications as follows: - Added Amlodipine for blood pressure 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]
[]
[ "I480", "I10", "D649", "Z8673" ]
[ "I63542: Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery", "M317: Microscopic polyangiitis", "N184: Chronic kidney disease, stage 4 (severe)", "E854: Organ-limited amyloidosis", "I680: Cerebral amyloid angiopathy", "I6389: Other cerebral infarction", "R42: Dizziness and giddiness", "R2689: Other abnormalities of gait and mobility", "H532: Diplopia", "R419: Unspecified symptoms and signs involving cognitive functions and awareness", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "R29701: NIHSS score 1", "I671: Cerebral aneurysm, nonruptured", "D649: Anemia, unspecified", "Z23: Encounter for immunization", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z2239: Carrier of other specified bacterial diseases" ]
10,051,043
27,233,968
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Double vision, dizziness, gait unsteadiness Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: NEUROLOGY STROKE ADMISSION NOTE ___ ___ (BID #: ___) CC: double vision, transfer from ___ HPI: ___ woman, previously seen here on the stroke service in ___, with a history of microscopic polyangiitis (MPO+/PR3-)complicated by DAH, glomerulonephritis, and episcleritis who presented to ___ on ___ with one day of horizontal diplopia. 2 days prior to admission she was driving back from dinner and noticed that her vision "changed". She said it was difficult to describe but it was hard to tell "where the edge of the car was and where the edge of the rode was". She awoke on the morning of ___ with a mild headache. When she stood up to walk she noted room spinning and needed to use the guard rail to stay steady. She did not have any other symptoms at that time. She looked in the mirror and noted that her left eye appeared "abnormal". She noted double vision (horizontal) that has been persistent but now is improving per patient. She was admitted to the medicine service with neurology consult. No TPA was given that symptom onset was unknown. While admitted she underwent a CTA head and neck (final read pending) without LVO. She had an MRI w/o contrast today which showed a subacute infarct in the midbrain on the L of the ___ nerve nucleus. She also was shown to have few possible microhemorrhages on SWI sequence. Neurology suggested 81mg aspirin and transfer to ___ Neuro for work up of possible CNS vasculitis and rheumatology consult. Patient reports that she has not been taking apixaban or any of her other prescribed medications(which was started in ___ for paroxysmal afib). Regarding her prior history, the patient was initially diagnosed with MPA in ___ initially treated with steroids and then cyclophosphamide. She was suggested to start AZA but patient did not want this medication. She did a few courses of Cytoxan in ___. She was re-admitted in ___ for recurrent DAH and episcleritis. She was given methylprednisone for this followed on prednisone. She was then started on rituximab but later bronch was done that was more suggestive of infection rather than DAH. Stroke history: First stroke in ___. Presented to ___ in ___ with L NLFF and LUE weakness. MRI showed an acute infarction in the R putamen/corona radiate and L inferior caudate head. She was started on aspirin 81mg at this time but it was later discontinued in ___ after she developed diffuse alveolar hemorrhage. Presented in ___ with L sided weakness to ___ and transferred to ___. On MRI she was found to have a new infarct of the L internal capsule and a L parietal subacute stroke. She was subsequently found on admission here to have paroxysmal A-fib with rvr and was started on apixaban. Etiology of stroke was thought to be due to afib and less likely due to cns vasculitis as she was not having an active vasculitis flare systemically. Furthermore there was no beading on CTA . LP was deferred at this time. On neuro ROS, the pt endorses mild horizontal diplopia when looking to the right, she says it has improved greatly since it started. She also endorses difficulty walking but can't say if she felt unsteady or if it is due to the difficulty seeing. She denies headache, loss of vision, blurred vision, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the 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 or joint pain. PMH: Microscopic Polyangiitis: Diffuse alveolar hemorrhage and glomerulonephritis Chronic Kidney Disease Paroxysmal Atrial Fibrllation History of subacute Stroke: Posterior limb of L internal capsule History of multifocal small vessel strokes Diffuse Alveolar Hemorrhage Lyme disease (possible). Per notes, diagnosed in ___. Symptomatic episodes including arthralgias, Raynaud's, extremity pain and weakness. Treated with multiple courses of erythromycin/tetracycline in the past over the course of ___ years with a "Lyme specialist." However, it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis Home Medications: takes no home medications other than protonics Allergies: No allergies Social Hx: Lives with her son who is ___ in ___. She has been doing temp work. Used to be a SW and just did a few months at ___ as Psych SW. Does all her own ADLs. Denies any smoking, ___ drinks a year, denies any other drugs. - 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 Hx: Reviewed and found to be not relevant to this illness/reason for hospitalization. Past Medical History: -Microscopic polyangiitis With previous complications of diffuse alveolar hemorrhage and glomerulonephritis. Initially diagnosed in ___. Prior treatments including: steroids, plasmapheresis, cyclophosphamide. -Prior Stroke ___. Presented with L NLFF and L UE weakness. MRI at ___ showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. -Paroxysmal Atrial Fibrillation Previously non-compliant on oral anticoagulation -Hypertension Previously non-compliant on anti-hypertensives Social History: ___ Family History: Mother with unknown cancer. Physical Exam: Initial Physical Examination 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: 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 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL 3 to 2mm and brisk. double vision with rightward gaze, unable to say which image went away with covering eyes, says "two fingers on side by side overlapping", left eye does not fully adduct, nystagmus with right ward gaze, facial sensation intact to light touch, face is symmetric other than mild ptosis on left (baseline per patient),Hearing intact to finger-rub bilaterally, Palate elevates symmetrically, ___ strength in trapezii bilaterally. Tongue protrudes in midline with good excursions. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. No rebound Delt Bic Tri WrE FE 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 throughout. No extinction to DSS. -DTRs: ___ Tri ___ Pat Ach L 2+ 2+ 2+ 2+ 2 R 2+ 2+ 2+ 2+ 2 Plantar response was flexor on right, extensor on left -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. =========================================================== Discharge Physical Examination: Mild horizontal diplopia when looking to the right, unable to say which image goes away when closing eyes. she says its two images on top of each other. Cannot fully adduct left eye, mild ptosis on left (baseline per patient), rest of exam is normal. Pertinent Results: ___ 06:58PM BLOOD WBC-8.3 RBC-3.64* Hgb-10.4* Hct-33.4* MCV-92 MCH-28.6 MCHC-31.1* RDW-12.5 RDWSD-42.1 Plt ___ ___ 05:35AM BLOOD WBC-8.1 RBC-3.35* Hgb-9.7* Hct-30.5* MCV-91 MCH-29.0 MCHC-31.8* RDW-12.5 RDWSD-41.4 Plt ___ ___ 06:58PM BLOOD Plt ___ ___ 06:58PM BLOOD ___ PTT-25.2 ___ ___ 05:35AM BLOOD Plt ___ ___ 06:58PM BLOOD Glucose-86 UreaN-26* Creat-1.4* Na-140 K-5.1 Cl-103 HCO3-28 AnGap-9* ___ 05:35AM BLOOD Glucose-94 UreaN-18 Creat-1.4* Na-138 K-4.2 Cl-100 HCO3-25 AnGap-13 ___ 05:25AM BLOOD ALT-8 AST-10 LD(LDH)-133 AlkPhos-104 TotBili-0.2 ___ 06:58PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 ___ 05:35AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9 ___ 05:25AM BLOOD %HbA1c-5.2 eAG-103 ___ 05:25AM BLOOD Triglyc-60 HDL-45 CHOL/HD-3.0 LDLcalc-79 ___ 05:25AM BLOOD Albumin-3.1* Cholest-136 ___ 05:25AM BLOOD TSH-5.2* ___ 03:10PM BLOOD ANCA-PND ___ 05:25AM BLOOD CRP-8.5* ___ 05:25AM BLOOD SED RATE-Test CTA ___ (at ___ IMPRESSION: 1. No acute intracranial abnormality by unenhanced head CT. 2. Very limited CTA head and neck due to poor opacification of the arterial vessels as above. Within these confines, there are areas of mild narrowing of the bilateral intracranial ICAs due to calcified plaque. Otherwise, the remainder of the circle ___ vasculature appears patent without stenosis, occlusion or aneurysm. Patent bilateral cervical and vertebral arteries, with areas of poor visualization of the thoracic inlet skullbase, as above. No discernible ICA stenosis by NASCET criteria. 3. Chronic intracranial findings include global parenchymal volume loss and moderate changes of chronic white matter microangiopathy. 4. Small chronic lacunar infarcts in the left internal capsule and right corona radiata, seen on prior MR examinations. 5. Diffuse pulmonary interstitial abnormality, as described above, similar to prior exams. Other incidental findings, as above. ___ Labs ___ WBC 8, RBC 8, Protein 54, Glucose 59 Echo (trans-thoracic) ___ EF 55-60%; no evidence of intracardiac shunt; no evidence of thrombus MRI brain w/wo contrast ___ IMPRESSION: 1. Redemonstration of acute or early subacute infarct in the left midbrain, left internal capsule. No evidence of hemorrhagic transformation. 2. Multiple micro bleeds suggesting amyloid angiopathy. 3. No abnormal contrast enhancement. 4. Multiple chronic infarctions. Brief Hospital Course: Ms. ___ is a ___ year-old, right-handed female with past medical history significant for prior stroke, hypertension, paroxysmal atrial fibrillation, and microscopic polyangiitis. At baseline, she lives independently, although her family states that she has been increasingly withdrawn over the past several months. She is also admittedly non-compliant with medications (including anti-hypertensives and oral anticoagulation). During this admission, she was found to have an acute infarction of the left midbrain - not treated with IV-tPA or mechanical thrombectomy. She had a relatively ___ hospital course, and was discharged home in stable condition. #Acute Ischemic Infarction Exam is notable for horizontal binocular diplopia and ataxia as a consequence of an acute ischemic infarction involving the left midbrain and anterior limb of the left internal capsule. IV-tPA was not provided as the patient had an unknown last known well time; mechanical thrombectomy was not offered as she did not have an LVO. Etiology is most consistent with cardioembolic from known atrial fibrillation, although small vessel ischemic disease is still a possibility given her poorly-controlled hypertension. During this admission, CTA head/neck was negative for a large vessel occlusion. Transthoracic echocardiogram was unremarkable. Risk factor labs showed HbA1c 5.2 and LDL 79. She had an MRI brain at the outside hospital (without contrast) which was significant for the acute strokes. While admitted at ___, she had an MRI with contrast that showed several microhemorrhages on the SWI sequence, as well as a small enhancing area near the interpeduncular cistern. The enhancing lesion was reviewed with the radiologist who stated that the appearance was most consistent with a draining vein rather than an inflammatory lesion. Given her history of rheumatologic disease, an LP was performed to exclude an inflammatory lesion as the etiology for her infarctions. The CSF was not consistent with an ongoing CNS vasculitis (LP Labs: 8 WBC, 8 RBCs, 54 protein, normal glucose). Rheumatology did not suggest any changes to the plan at this time, although they requested a serum ANCA and it is pending. She was evaluated by ___ who recommended discharge to home. At time of discharge, we recommended that she resume her oral anticoagulation, and restart anti-hypertensive medications. We also added a statin for secondary stroke prevention. We arranged follow up with a new PCP as she did not like her prior PCP, and this may have been contributing to some of her medication non-compliance. She will follow-up with neurology to continue to monitor and modify her vascular risk factors. At time of discharge, her symptoms were subjectively/objectively improving, with the patient only reporting "shadow images" in certain directions of gaze, as well as a mild left upper/lower extremity ataxia. #Atrial Fibrillation (chronic) Was not compliant with oral anticoagulation prior to admission. Her apixaban was restarted ___. She was monitored on telemetry this admission, and a TTE was performed -- both of which were unremarkable. She was started on carvedilol 3.125mg BID for rate control. #Microscopic Polyangiitis (chronic) The patient was initially diagnosed with MPA (MPO+/PR3-) in ___ and initially treated with steroids and then cyclophosphamide. She was suggested to start AZA but patient did not want this medication. She did a few courses of Cytoxan in ___. She was re-admitted in ___ for recurrent diffuse alveolar hemorrhage and episcleritis. She was given methylprednisone for this followed on prednisone. She was then started on rituximab but later bronch was done that was more suggestive of infection rather than DAH. She also had glomerulonephritis with CKD. We did not find a relation to her acute neurologic issues this admission (ex CNS vasculitis). Rheumatology did not make any new recommendations - although serum ANCA is still pending. #CKD in Context of Glomerulonephritis (chronic) -Baseline creatinine 1.2 - 1.4; was at baseline this admission. #Elevated TSH -Incidental finding of low TSH this admission; T4 needs to be followed up on. #+Mycobacterium on BAL in ___: -Rheumatology recommends that patient sees I.D. in clinic in the near future for +BAL in ___, important as patient may need immunosuppressive therapy in the future. #Psych/Behavioral Assessment -Family endorses recent history of depressed mood and decreased motivation; anhedonia. This may be a contributor to her medication non-compliance as well. A MOCHA was performed and she scored a ___ suggesting no cognitive decline at this time. Social work was involved, and this can continue to be monitored by her PCP on an outpatient basis. She also does not have part D of medicare, and social work was able to show her how to set that up and in the meantime get cost coverage for apixaban. ============================== Transitional Issues: -Continued monitoring of vascular risk factors (HTN, Afib) -Continued monitoring of medication compliance and application for part D of Medicare -Will need follow up on serum ANCA, and serum T4 -Will need follow up on remainder of LP labs pending at discharge (HSV, ACE, MS panel). -___ eventually require outpatient evaluation by psychiatry/psychology for depressed mood and social withdrawal -Will need her ability to drive monitored; at the time of discharge, we recommended NOT driving for a period of time following her stroke as she was still experiencing some diplopia -PCP also to follow up that patient had +BAL for mycobacterium in ___, Rheumatology recommends that patient sees ID sometime in the near future in case she needs immunosuppression in the future**** -PCP consider hearing test as patient exhibits some hearing loss on exam ===================================== 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-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - If no, why not (I.e. bleeding risk, etc.) () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - ___ - ___ 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral Daily Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills:*3 2. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*3 3. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills:*3 4. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - ___ - ___ 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral Daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of dizziness and double vision 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: -Prior Stroke -Hypertension -Paroxysmal Atrial Fibrillation We are changing your medications as follows: -Start apixaban -Start Carvedilol -Start atorvastatin Please follow up with Neurology and your primary care physician: -___ (Stroke physician): Dr. ___ ___ at 4:00 ___ -Primary Care Physician: Dr. ___ ___ PCP) ___ at 1:40 ___ Building, ___ floor central suite. *The rheumatologist that saw you in the hospital will call you with an appointment with your previous rheumatologist - For your information, here is the contact information for the ___ Integrated Medicine Clinic (we did not create an appointment). If you are interested, for more information, please call ___ or e-mail ___. 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: ___
[ "I6340", "M317", "N038", "E854", "H532", "R260", "Z8673", "N189", "I480", "Z9114", "J99", "N08", "R946", "F329", "R4584", "I10" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Double vision, dizziness, gait unsteadiness Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: NEUROLOGY STROKE ADMISSION NOTE [MASKED] [MASKED] (BID #: [MASKED]) CC: double vision, transfer from [MASKED] HPI: [MASKED] woman, previously seen here on the stroke service in [MASKED], with a history of microscopic polyangiitis (MPO+/PR3-)complicated by DAH, glomerulonephritis, and episcleritis who presented to [MASKED] on [MASKED] with one day of horizontal diplopia. 2 days prior to admission she was driving back from dinner and noticed that her vision "changed". She said it was difficult to describe but it was hard to tell "where the edge of the car was and where the edge of the rode was". She awoke on the morning of [MASKED] with a mild headache. When she stood up to walk she noted room spinning and needed to use the guard rail to stay steady. She did not have any other symptoms at that time. She looked in the mirror and noted that her left eye appeared "abnormal". She noted double vision (horizontal) that has been persistent but now is improving per patient. She was admitted to the medicine service with neurology consult. No TPA was given that symptom onset was unknown. While admitted she underwent a CTA head and neck (final read pending) without LVO. She had an MRI w/o contrast today which showed a subacute infarct in the midbrain on the L of the [MASKED] nerve nucleus. She also was shown to have few possible microhemorrhages on SWI sequence. Neurology suggested 81mg aspirin and transfer to [MASKED] Neuro for work up of possible CNS vasculitis and rheumatology consult. Patient reports that she has not been taking apixaban or any of her other prescribed medications(which was started in [MASKED] for paroxysmal afib). Regarding her prior history, the patient was initially diagnosed with MPA in [MASKED] initially treated with steroids and then cyclophosphamide. She was suggested to start AZA but patient did not want this medication. She did a few courses of Cytoxan in [MASKED]. She was re-admitted in [MASKED] for recurrent DAH and episcleritis. She was given methylprednisone for this followed on prednisone. She was then started on rituximab but later bronch was done that was more suggestive of infection rather than DAH. Stroke history: First stroke in [MASKED]. Presented to [MASKED] in [MASKED] with L NLFF and LUE weakness. MRI showed an acute infarction in the R putamen/corona radiate and L inferior caudate head. She was started on aspirin 81mg at this time but it was later discontinued in [MASKED] after she developed diffuse alveolar hemorrhage. Presented in [MASKED] with L sided weakness to [MASKED] and transferred to [MASKED]. On MRI she was found to have a new infarct of the L internal capsule and a L parietal subacute stroke. She was subsequently found on admission here to have paroxysmal A-fib with rvr and was started on apixaban. Etiology of stroke was thought to be due to afib and less likely due to cns vasculitis as she was not having an active vasculitis flare systemically. Furthermore there was no beading on CTA . LP was deferred at this time. On neuro ROS, the pt endorses mild horizontal diplopia when looking to the right, she says it has improved greatly since it started. She also endorses difficulty walking but can't say if she felt unsteady or if it is due to the difficulty seeing. She denies headache, loss of vision, blurred vision, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the 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 or joint pain. PMH: Microscopic Polyangiitis: Diffuse alveolar hemorrhage and glomerulonephritis Chronic Kidney Disease Paroxysmal Atrial Fibrllation History of subacute Stroke: Posterior limb of L internal capsule History of multifocal small vessel strokes Diffuse Alveolar Hemorrhage Lyme disease (possible). Per notes, diagnosed in [MASKED]. Symptomatic episodes including arthralgias, Raynaud's, extremity pain and weakness. Treated with multiple courses of erythromycin/tetracycline in the past over the course of [MASKED] years with a "Lyme specialist." However, it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis Home Medications: takes no home medications other than protonics Allergies: No allergies Social Hx: Lives with her son who is [MASKED] in [MASKED]. She has been doing temp work. Used to be a SW and just did a few months at [MASKED] as Psych SW. Does all her own ADLs. Denies any smoking, [MASKED] drinks a year, denies any other drugs. - 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 Hx: Reviewed and found to be not relevant to this illness/reason for hospitalization. Past Medical History: -Microscopic polyangiitis With previous complications of diffuse alveolar hemorrhage and glomerulonephritis. Initially diagnosed in [MASKED]. Prior treatments including: steroids, plasmapheresis, cyclophosphamide. -Prior Stroke [MASKED]. Presented with L NLFF and L UE weakness. MRI at [MASKED] showed acute infarction in the right putamen, corona radiata and in the left inferior caudate head. -Paroxysmal Atrial Fibrillation Previously non-compliant on oral anticoagulation -Hypertension Previously non-compliant on anti-hypertensives Social History: [MASKED] Family History: Mother with unknown cancer. Physical Exam: Initial Physical Examination 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: 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 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL 3 to 2mm and brisk. double vision with rightward gaze, unable to say which image went away with covering eyes, says "two fingers on side by side overlapping", left eye does not fully adduct, nystagmus with right ward gaze, facial sensation intact to light touch, face is symmetric other than mild ptosis on left (baseline per patient),Hearing intact to finger-rub bilaterally, Palate elevates symmetrically, [MASKED] strength in trapezii bilaterally. Tongue protrudes in midline with good excursions. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. No rebound Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 5 5 5 5 [MASKED] 5 5 5 5 R 5 5 5 5 [MASKED] 5 5 5 5 -Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. -DTRs: [MASKED] Tri [MASKED] Pat Ach L 2+ 2+ 2+ 2+ 2 R 2+ 2+ 2+ 2+ 2 Plantar response was flexor on right, extensor on left -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. =========================================================== Discharge Physical Examination: Mild horizontal diplopia when looking to the right, unable to say which image goes away when closing eyes. she says its two images on top of each other. Cannot fully adduct left eye, mild ptosis on left (baseline per patient), rest of exam is normal. Pertinent Results: [MASKED] 06:58PM BLOOD WBC-8.3 RBC-3.64* Hgb-10.4* Hct-33.4* MCV-92 MCH-28.6 MCHC-31.1* RDW-12.5 RDWSD-42.1 Plt [MASKED] [MASKED] 05:35AM BLOOD WBC-8.1 RBC-3.35* Hgb-9.7* Hct-30.5* MCV-91 MCH-29.0 MCHC-31.8* RDW-12.5 RDWSD-41.4 Plt [MASKED] [MASKED] 06:58PM BLOOD Plt [MASKED] [MASKED] 06:58PM BLOOD [MASKED] PTT-25.2 [MASKED] [MASKED] 05:35AM BLOOD Plt [MASKED] [MASKED] 06:58PM BLOOD Glucose-86 UreaN-26* Creat-1.4* Na-140 K-5.1 Cl-103 HCO3-28 AnGap-9* [MASKED] 05:35AM BLOOD Glucose-94 UreaN-18 Creat-1.4* Na-138 K-4.2 Cl-100 HCO3-25 AnGap-13 [MASKED] 05:25AM BLOOD ALT-8 AST-10 LD(LDH)-133 AlkPhos-104 TotBili-0.2 [MASKED] 06:58PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 [MASKED] 05:35AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9 [MASKED] 05:25AM BLOOD %HbA1c-5.2 eAG-103 [MASKED] 05:25AM BLOOD Triglyc-60 HDL-45 CHOL/HD-3.0 LDLcalc-79 [MASKED] 05:25AM BLOOD Albumin-3.1* Cholest-136 [MASKED] 05:25AM BLOOD TSH-5.2* [MASKED] 03:10PM BLOOD ANCA-PND [MASKED] 05:25AM BLOOD CRP-8.5* [MASKED] 05:25AM BLOOD SED RATE-Test CTA [MASKED] (at [MASKED] IMPRESSION: 1. No acute intracranial abnormality by unenhanced head CT. 2. Very limited CTA head and neck due to poor opacification of the arterial vessels as above. Within these confines, there are areas of mild narrowing of the bilateral intracranial ICAs due to calcified plaque. Otherwise, the remainder of the circle [MASKED] vasculature appears patent without stenosis, occlusion or aneurysm. Patent bilateral cervical and vertebral arteries, with areas of poor visualization of the thoracic inlet skullbase, as above. No discernible ICA stenosis by NASCET criteria. 3. Chronic intracranial findings include global parenchymal volume loss and moderate changes of chronic white matter microangiopathy. 4. Small chronic lacunar infarcts in the left internal capsule and right corona radiata, seen on prior MR examinations. 5. Diffuse pulmonary interstitial abnormality, as described above, similar to prior exams. Other incidental findings, as above. [MASKED] Labs [MASKED] WBC 8, RBC 8, Protein 54, Glucose 59 Echo (trans-thoracic) [MASKED] EF 55-60%; no evidence of intracardiac shunt; no evidence of thrombus MRI brain w/wo contrast [MASKED] IMPRESSION: 1. Redemonstration of acute or early subacute infarct in the left midbrain, left internal capsule. No evidence of hemorrhagic transformation. 2. Multiple micro bleeds suggesting amyloid angiopathy. 3. No abnormal contrast enhancement. 4. Multiple chronic infarctions. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old, right-handed female with past medical history significant for prior stroke, hypertension, paroxysmal atrial fibrillation, and microscopic polyangiitis. At baseline, she lives independently, although her family states that she has been increasingly withdrawn over the past several months. She is also admittedly non-compliant with medications (including anti-hypertensives and oral anticoagulation). During this admission, she was found to have an acute infarction of the left midbrain - not treated with IV-tPA or mechanical thrombectomy. She had a relatively [MASKED] hospital course, and was discharged home in stable condition. #Acute Ischemic Infarction Exam is notable for horizontal binocular diplopia and ataxia as a consequence of an acute ischemic infarction involving the left midbrain and anterior limb of the left internal capsule. IV-tPA was not provided as the patient had an unknown last known well time; mechanical thrombectomy was not offered as she did not have an LVO. Etiology is most consistent with cardioembolic from known atrial fibrillation, although small vessel ischemic disease is still a possibility given her poorly-controlled hypertension. During this admission, CTA head/neck was negative for a large vessel occlusion. Transthoracic echocardiogram was unremarkable. Risk factor labs showed HbA1c 5.2 and LDL 79. She had an MRI brain at the outside hospital (without contrast) which was significant for the acute strokes. While admitted at [MASKED], she had an MRI with contrast that showed several microhemorrhages on the SWI sequence, as well as a small enhancing area near the interpeduncular cistern. The enhancing lesion was reviewed with the radiologist who stated that the appearance was most consistent with a draining vein rather than an inflammatory lesion. Given her history of rheumatologic disease, an LP was performed to exclude an inflammatory lesion as the etiology for her infarctions. The CSF was not consistent with an ongoing CNS vasculitis (LP Labs: 8 WBC, 8 RBCs, 54 protein, normal glucose). Rheumatology did not suggest any changes to the plan at this time, although they requested a serum ANCA and it is pending. She was evaluated by [MASKED] who recommended discharge to home. At time of discharge, we recommended that she resume her oral anticoagulation, and restart anti-hypertensive medications. We also added a statin for secondary stroke prevention. We arranged follow up with a new PCP as she did not like her prior PCP, and this may have been contributing to some of her medication non-compliance. She will follow-up with neurology to continue to monitor and modify her vascular risk factors. At time of discharge, her symptoms were subjectively/objectively improving, with the patient only reporting "shadow images" in certain directions of gaze, as well as a mild left upper/lower extremity ataxia. #Atrial Fibrillation (chronic) Was not compliant with oral anticoagulation prior to admission. Her apixaban was restarted [MASKED]. She was monitored on telemetry this admission, and a TTE was performed -- both of which were unremarkable. She was started on carvedilol 3.125mg BID for rate control. #Microscopic Polyangiitis (chronic) The patient was initially diagnosed with MPA (MPO+/PR3-) in [MASKED] and initially treated with steroids and then cyclophosphamide. She was suggested to start AZA but patient did not want this medication. She did a few courses of Cytoxan in [MASKED]. She was re-admitted in [MASKED] for recurrent diffuse alveolar hemorrhage and episcleritis. She was given methylprednisone for this followed on prednisone. She was then started on rituximab but later bronch was done that was more suggestive of infection rather than DAH. She also had glomerulonephritis with CKD. We did not find a relation to her acute neurologic issues this admission (ex CNS vasculitis). Rheumatology did not make any new recommendations - although serum ANCA is still pending. #CKD in Context of Glomerulonephritis (chronic) -Baseline creatinine 1.2 - 1.4; was at baseline this admission. #Elevated TSH -Incidental finding of low TSH this admission; T4 needs to be followed up on. #+Mycobacterium on BAL in [MASKED]: -Rheumatology recommends that patient sees I.D. in clinic in the near future for +BAL in [MASKED], important as patient may need immunosuppressive therapy in the future. #Psych/Behavioral Assessment -Family endorses recent history of depressed mood and decreased motivation; anhedonia. This may be a contributor to her medication non-compliance as well. A MOCHA was performed and she scored a [MASKED] suggesting no cognitive decline at this time. Social work was involved, and this can continue to be monitored by her PCP on an outpatient basis. She also does not have part D of medicare, and social work was able to show her how to set that up and in the meantime get cost coverage for apixaban. ============================== Transitional Issues: -Continued monitoring of vascular risk factors (HTN, Afib) -Continued monitoring of medication compliance and application for part D of Medicare -Will need follow up on serum ANCA, and serum T4 -Will need follow up on remainder of LP labs pending at discharge (HSV, ACE, MS panel). -[MASKED] eventually require outpatient evaluation by psychiatry/psychology for depressed mood and social withdrawal -Will need her ability to drive monitored; at the time of discharge, we recommended NOT driving for a period of time following her stroke as she was still experiencing some diplopia -PCP also to follow up that patient had +BAL for mycobacterium in [MASKED], Rheumatology recommends that patient sees ID sometime in the near future in case she needs immunosuppression in the future**** -PCP consider hearing test as patient exhibits some hearing loss on exam ===================================== 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-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - If no, why not (I.e. bleeding risk, etc.) () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - [MASKED] - [MASKED] 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral Daily Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills:*3 2. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*3 3. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills:*3 4. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - [MASKED] - [MASKED] 40-Bifido 3-S.thermop;<br>Lactobacillus acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral Daily Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of dizziness and double vision 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: -Prior Stroke -Hypertension -Paroxysmal Atrial Fibrillation We are changing your medications as follows: -Start apixaban -Start Carvedilol -Start atorvastatin Please follow up with Neurology and your primary care physician: -[MASKED] (Stroke physician): Dr. [MASKED] [MASKED] at 4:00 [MASKED] -Primary Care Physician: Dr. [MASKED] [MASKED] PCP) [MASKED] at 1:40 [MASKED] Building, [MASKED] floor central suite. *The rheumatologist that saw you in the hospital will call you with an appointment with your previous rheumatologist - For your information, here is the contact information for the [MASKED] Integrated Medicine Clinic (we did not create an appointment). If you are interested, for more information, please call [MASKED] or e-mail [MASKED]. 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]
[]
[ "Z8673", "N189", "I480", "F329", "I10" ]
[ "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "M317: Microscopic polyangiitis", "N038: Chronic nephritic syndrome with other morphologic changes", "E854: Organ-limited amyloidosis", "H532: Diplopia", "R260: Ataxic gait", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "N189: Chronic kidney disease, unspecified", "I480: Paroxysmal atrial fibrillation", "Z9114: Patient's other noncompliance with medication regimen", "J99: Respiratory disorders in diseases classified elsewhere", "N08: Glomerular disorders in diseases classified elsewhere", "R946: Abnormal results of thyroid function studies", "F329: Major depressive disorder, single episode, unspecified", "R4584: Anhedonia", "I10: Essential (primary) hypertension" ]
10,051,043
29,090,306
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hemoptysis, eye redness Major Surgical or Invasive Procedure: ___: Bronchoscopy with Lavage History of Present Illness: ___ with h/o MPA (MPO Ab positive) with prior pulmonary involvement (DAH) and renal involvement (GN) who presents with 3 episodes of hemoptysis over the past day. Patient describes ~ 1.5 tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at ___. She states this is similar to her intial presentation in ___. She was transferred to ___ for further work up and evaluation. Patient has also complained of mild RUQ pain for the past several days. On further questioning, patient also reports ongoing cough for ~ 1 week productive of phlegm. No fevers, chills, N/V. No recent weight loss. No recent sick contacts, however works as a ___ with adolescents. Has been under increased stress this past week as she was just let go from her job. On initial presentation to the ___ ED, vitals notable for: 97.9 87 158/79 14 94% RA. Exam notable for NAD and normal pulmonary exam. Labs notable for normal Chem 7, WBC 6.8, Hgb 10.1, CRP 9.1. Of note, she was admitted in ___ with hemoptysis requiring intubation as well as renal failure. She was found to have MPA (based on high p-ANCA titers) and treated with high dose steroids, Cytoxan, and plasma exchange. She clinically and radiographically improved after this therapy. She was tapered off prednisone and completed induction therapy for vasculitis in ___ with Cytoxan, but declined maintenance therapy due to c/f hair loss and financial difficulties. She is followed by rheumatology here. At her last visit in ___ she was felt to be in remission, but she was felt to be at high risk of relapse and was recommended to start azathioprine however she has not done this. On arrival to the MICU, patient HD stable without complaint, however requiring 3L o2 to maintain sats in high ___. Past Medical History: - MPA with DAH and Glomerular Nephritis - Lyme disease (dagnosed in ___, with prior sx including arthralgia, "inflammation behind the eye", Raynauds, rashes, and extremity pain/weakness; treated with erythromycin/tetracycline in the past) - sp CVA ___ Social History: ___ Family History: mother with history of unknown cancer Physical Exam: Physical Exam on Admission: Vitals: Afebrile, 74, 155/93, 15; 99% 3L GENERAL: Alert, oriented, no acute distress HEENT: L sclera injected, inflamed, no drainage, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Normal inspiratory effort, initial crackles that cleared with cough; otherwise no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes, lesions noted NEURO: A&Ox3. Moving all extremities with purpose ============================================================== Physical Exam on Discharge: Vitals: T: 98.1 BP: 110-120s/60s P: 60-70 R:16 O2: 98%RA General: Alert, oriented, no acute distress HEENT: L medial sclera interval improvement in erythema, now normal appearing. MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, faint bibasilar crackles, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes Neuro: AAOx3, PERRL, EOMI, moving all extremities, sensation grossly in tact. Pertinent Results: Labs on Admission: ___ 04:45AM BLOOD WBC-6.8# RBC-3.36* Hgb-10.1* Hct-31.0* MCV-92 MCH-30.1# MCHC-32.6 RDW-12.5 RDWSD-41.8 Plt ___ ___ 04:45AM BLOOD Neuts-67.6 ___ Monos-8.0 Eos-4.3 Baso-0.6 Im ___ AbsNeut-4.58 AbsLymp-1.30 AbsMono-0.54 AbsEos-0.29 AbsBaso-0.04 ___ 04:45AM BLOOD ___ PTT-19.4* ___ ___ 04:45AM BLOOD Glucose-112* UreaN-28* Creat-1.1 Na-139 K-4.2 Cl-103 HCO3-24 AnGap-16 ___ 04:45AM BLOOD ALT-15 AST-19 AlkPhos-113* TotBili-0.2 ___ 04:45AM BLOOD CRP-9.1* ============================================================ Pertinent Results: ___ 01:01PM BLOOD CD19%-9.83 CD19Abs-113.24 CD20%-9.66 CD20Abs-111.28 ___ 12:59PM BLOOD ANCA-POSITIVE * ANCATtr-1:160 ___ 07:31AM BLOOD HBsAg-NEGATIVE ___ 01:01PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 01:01PM BLOOD IgG-1019 IgA-288 IgM-179 ___ 04:45AM BLOOD C3-109 C4-22 ___ 05:30PM BLOOD HIV Ab-Negative ___ 01:15PM BLOOD SED RATE-Test ============================================================ Labs on Discharge: ___ 07:55AM BLOOD WBC-8.6 RBC-3.34* Hgb-10.0* Hct-31.4* MCV-94 MCH-29.9 MCHC-31.8* RDW-13.0 RDWSD-44.2 Plt ___ ___ 07:55AM BLOOD Plt ___ ___ 07:55AM BLOOD Glucose-86 UreaN-38* Creat-1.4* Na-140 K-5.1 Cl-104 HCO3-29 AnGap-12 ___ 07:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1 ============================================================= MICRO: ___ 11:15 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 4:55 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 3:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. ~1000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. WORKUP REQUESTED ___ BY ___ ___. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 3:39 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ___ QuantiFeron Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD INDETERMINATE A NEGATIVE Results are indeterminate for response to ESAT-6,TB7.7 and/or CFP-10 test antigens. Test Result Reference Range/Units NIL 0.02 IU/mL MITOGEN-NIL 0.22 IU/mL TB-NIL <0.00 IU/mL ============================================================ Clinical Studies/Procedures/Imaging: CT Chest: ___ 1. Diffuse areas of ground-glass opacity in a peribronchovascular distribution could represent an inflammatory disorder, an infectious process, or diffuse alveolar hemorrhage, depending on the clinical setting. 2. Several more nodular opacities are seen bilaterally which may represent extension of the underlying process described above, however short interval follow-up chest CT after symptoms have resolved is recommended to ensure resolution. ___: Bronch lavage: 4ml bloody fluid. Negative for malignant cells Pulmonary macrophages, epithelial cells. Some containing hemosiderin. Brief Hospital Course: Ms. ___ is a ___ y/o F w/ ANCA-associated vasculitis (MPA) status post induction therapy with six months of oral cyclophosphamide and prednisone and no maintenance since completing induction therapy in ___ who was admitted for hemoptysis and eye redness. #MPA c/b DAH, glomerulonephritis and episcleritis: Patient initially presented to the hospital after coughing up 1.5 tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at ___. She states this is similar to her last presentation in ___ with MPA c/b DAH flare. She was transferred to ___ for further work up and evaluation. In terms of her MPA treatment history, patient is status post induction therapy with six months of oral cyclophosphamide and prednisone, but no maintenance since completing induction therapy in ___. She reports that she decided against maintenance therapy due to concern for hair loss and cost of the medication. Here at ___, patient was diagnosed with MPA c/b diffuse alveolar hemorrhage, medial episcleritis and glomerulonephritis. Patient underwent a bronchoscopy procedure by IP which visualized large blood, cultures + for 1000/ml pseudomonas (see problem below), but no cells concerning for malignancy. The bleeding spontaneously stopped and her Hgb was stable at 10. Further labs were notable for +ANCA 1:160 titer, CRP 9.1, and normal immunoglobulin levels. She also had ___ (Cr 1.3-1.4 from baseline of 1.1) with microscopy positive for RBCs and acanthocytes, diagnostic of glomerulonephritis. Patient was seen by her outpatient nephrologist Dr. ___, who recommended continuing treatment per rheumatology recommendations. Patient was evaluated by ophthalmology who also deferred treatment to rheumatology for management. The rheumatology consult team recommended 3 days of pulse methylpred followed by initiation of prednisone 60mg daily to be tapered in the outpatient setting. She will take Bactrim SS daily for PCP ___. Additionally, it was recommended that patient start Qweekly Rituxan therapy for 4 weeks (day ___. Due to patient having an indeterminate quantiferon gold test in the setting of being on prednisone, the ID team recommended starting concurrent INH for 9 months. However, due to concern for side effects (i.e. neuropathy), patient declined INH treatment. A thorough discussion was held with the patient regarding the risk of developing a life-threatening active tuberculosis infection, and she fully understood these risks in making her decision. Patient will follow-up with her primary care, rheumatology and nephrology physicians as outpatient. At the time of discharge, patient was breathing comfortably on room air, with complete resolution of her eye symptoms and had a Cr of 1.4. #Pseudomonas colonization: Patient grew pseudomonas 1000/ml from bronch lavage. Per ID, likely just colonization and no need for any treatment due to it not being pathogenic. It was recommended that if patient develops a fever or symptoms of pneumonia in the outpatient setting that there be a low threshold to treat. #Hep B non-immune: Patient has a negative HBs Ag and Ab. Per patient, she has never been immunized. She has initiated rituxan therapy and would benefit from outpatient Hep B vaccination. #Anemia: Patient has a history of anemia with Hgb ~12. During this admission, she was anemic to 10 but the H/H remained stable. The new drop was likely in the setting of hemoptysis from diffuse alveolar hemorrhage. She did not need any transfusions due to blood count stability. Please follow-up regarding her anemia in the outpatient setting. #RUQ Pain: At the time of admission, patient endorsed having some RUQ pain. This quickly resolved within 2 hours and was determined by the ICU team to be secondary to vigorous coughing. Patient did not have any other abdominal pain for the remainder of her hospitalization. = ================================================================ Transitional Issues: 1. Follow-up on her MPA c/b DAH and glomerulonephritis. Patient will have Qweekly Rituxan treatment x 4weeks (week 1 was done inpatient beginning ___. Patient also discharged on 60 mg prednisone daily (to be tapered by rheumatology at outpatient follow up) and Bactrim for PCP ___. Please obtain repeat Chemistry panel on ___ during outpatient appointment. 2. Follow-up regarding her Hep B non-immune status, patient would benefit from vaccination. 3. Please note per ID, due to indeterminate quant gold result while on steroids (obscures reliability of test result), patient should be on INH x 9 mo. However, after a thorough discussion with her, patient decided to decline while fully understanding the risks of developing an active TB infection while on Rituxan. Please follow-up and assess her interest in starting INH as outpatient. 4. CT chest demonstrated Several more nodular opacities are seen bilaterally which may represent extension of the underlying process (DAH). Please obtain repeat CT in 2 months per radiology. 5. Follow-up on final blood culture data (pending at time of discharge) 6. Please note patient grew pseudomonas 1000/ml from bronch lavage. Per ID, likely just colonization and no need for any treatment. If develops fever in outpatient, to have low threshold for treatment. # CODE: Full code (confirmed) # CONTACT: ___, ___ Medications on Admission: None Discharge Medications: 1. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth Once daily Disp #*30 Tablet Refills:*0 3. Vitamin D ___ UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth Once daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Microscopic polyangiitis c/b Diffuse alveolar hemorrhage and glomerulonephritis 2. Hep B non-immune Secondary Diagnoses: 1. Anemia 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 to care for you at ___ ___. You were hospitalized due to bleeding from your lung, as well as inflammation of your eye and kidneys. Due to this, you were in the intensive care unit and underwent a bronchoscopy procedure, which confirmed that you were bleeding from your lung. Your bleeding stopped on its own and you did not need any blood transfusions. The ophthalmology doctor evaluated your eye and recommended treatment based on rheumatology recommendations. The rheumatology doctors ___ and recommended treating you with 3 days of IV steroids, followed by continuing prednisone 60mg daily. Since beginning steroid treatment, your eye redness improved, and you had no other episodes of bleeding. You will follow-up with Dr. ___ in the outpatient setting, and she will start to taper your prednisone at that time. You will also need to take an antibiotic called Bactrim every day to prevent infections while you take the steroids. While you were here, it was also recommended that you initiate Rituxan therapy to better control your microscopic polyangiitis. This was discussed with the rheumatology doctors, infectious disease doctors ___ Dr. ___, ___ all agreed. Your quantiferon gold test result was indeterminate. Because of this the infectious disease doctors recommended that ___ start isoniazid while you are on the Rituxan. You elected to not take this medication due to potential side effects. We discussed the risks of potentially developing a life-threatening active tuberculosis infection, and you understood these considerations in reaching your decision. Please take all your medications as instructed, and follow-up with your outpatient doctors at the ___ listed below. If you develop any fever, chills, shortness of breath or acute weight loss, please present to the nearest emergency room. It was a pleasure to care for you while you were here. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "M317", "B1910", "N179", "R042", "R739", "N059", "D649", "H15109", "Z7952", "Z2239", "Z8673" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hemoptysis, eye redness Major Surgical or Invasive Procedure: [MASKED]: Bronchoscopy with Lavage History of Present Illness: [MASKED] with h/o MPA (MPO Ab positive) with prior pulmonary involvement (DAH) and renal involvement (GN) who presents with 3 episodes of hemoptysis over the past day. Patient describes ~ 1.5 tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at [MASKED]. She states this is similar to her intial presentation in [MASKED]. She was transferred to [MASKED] for further work up and evaluation. Patient has also complained of mild RUQ pain for the past several days. On further questioning, patient also reports ongoing cough for ~ 1 week productive of phlegm. No fevers, chills, N/V. No recent weight loss. No recent sick contacts, however works as a [MASKED] with adolescents. Has been under increased stress this past week as she was just let go from her job. On initial presentation to the [MASKED] ED, vitals notable for: 97.9 87 158/79 14 94% RA. Exam notable for NAD and normal pulmonary exam. Labs notable for normal Chem 7, WBC 6.8, Hgb 10.1, CRP 9.1. Of note, she was admitted in [MASKED] with hemoptysis requiring intubation as well as renal failure. She was found to have MPA (based on high p-ANCA titers) and treated with high dose steroids, Cytoxan, and plasma exchange. She clinically and radiographically improved after this therapy. She was tapered off prednisone and completed induction therapy for vasculitis in [MASKED] with Cytoxan, but declined maintenance therapy due to c/f hair loss and financial difficulties. She is followed by rheumatology here. At her last visit in [MASKED] she was felt to be in remission, but she was felt to be at high risk of relapse and was recommended to start azathioprine however she has not done this. On arrival to the MICU, patient HD stable without complaint, however requiring 3L o2 to maintain sats in high [MASKED]. Past Medical History: - MPA with DAH and Glomerular Nephritis - Lyme disease (dagnosed in [MASKED], with prior sx including arthralgia, "inflammation behind the eye", Raynauds, rashes, and extremity pain/weakness; treated with erythromycin/tetracycline in the past) - sp CVA [MASKED] Social History: [MASKED] Family History: mother with history of unknown cancer Physical Exam: Physical Exam on Admission: Vitals: Afebrile, 74, 155/93, 15; 99% 3L GENERAL: Alert, oriented, no acute distress HEENT: L sclera injected, inflamed, no drainage, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Normal inspiratory effort, initial crackles that cleared with cough; otherwise no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes, lesions noted NEURO: A&Ox3. Moving all extremities with purpose ============================================================== Physical Exam on Discharge: Vitals: T: 98.1 BP: 110-120s/60s P: 60-70 R:16 O2: 98%RA General: Alert, oriented, no acute distress HEENT: L medial sclera interval improvement in erythema, now normal appearing. MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, faint bibasilar crackles, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes Neuro: AAOx3, PERRL, EOMI, moving all extremities, sensation grossly in tact. Pertinent Results: Labs on Admission: [MASKED] 04:45AM BLOOD WBC-6.8# RBC-3.36* Hgb-10.1* Hct-31.0* MCV-92 MCH-30.1# MCHC-32.6 RDW-12.5 RDWSD-41.8 Plt [MASKED] [MASKED] 04:45AM BLOOD Neuts-67.6 [MASKED] Monos-8.0 Eos-4.3 Baso-0.6 Im [MASKED] AbsNeut-4.58 AbsLymp-1.30 AbsMono-0.54 AbsEos-0.29 AbsBaso-0.04 [MASKED] 04:45AM BLOOD [MASKED] PTT-19.4* [MASKED] [MASKED] 04:45AM BLOOD Glucose-112* UreaN-28* Creat-1.1 Na-139 K-4.2 Cl-103 HCO3-24 AnGap-16 [MASKED] 04:45AM BLOOD ALT-15 AST-19 AlkPhos-113* TotBili-0.2 [MASKED] 04:45AM BLOOD CRP-9.1* ============================================================ Pertinent Results: [MASKED] 01:01PM BLOOD CD19%-9.83 CD19Abs-113.24 CD20%-9.66 CD20Abs-111.28 [MASKED] 12:59PM BLOOD ANCA-POSITIVE * ANCATtr-1:160 [MASKED] 07:31AM BLOOD HBsAg-NEGATIVE [MASKED] 01:01PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [MASKED] 01:01PM BLOOD IgG-1019 IgA-288 IgM-179 [MASKED] 04:45AM BLOOD C3-109 C4-22 [MASKED] 05:30PM BLOOD HIV Ab-Negative [MASKED] 01:15PM BLOOD SED RATE-Test ============================================================ Labs on Discharge: [MASKED] 07:55AM BLOOD WBC-8.6 RBC-3.34* Hgb-10.0* Hct-31.4* MCV-94 MCH-29.9 MCHC-31.8* RDW-13.0 RDWSD-44.2 Plt [MASKED] [MASKED] 07:55AM BLOOD Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-86 UreaN-38* Creat-1.4* Na-140 K-5.1 Cl-104 HCO3-29 AnGap-12 [MASKED] 07:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1 ============================================================= MICRO: [MASKED] 11:15 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 4:55 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [MASKED] 3:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [MASKED]: PSEUDOMONAS AERUGINOSA. ~1000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. WORKUP REQUESTED [MASKED] BY [MASKED] [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] 3:39 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [MASKED] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. [MASKED] QuantiFeron Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD INDETERMINATE A NEGATIVE Results are indeterminate for response to ESAT-6,TB7.7 and/or CFP-10 test antigens. Test Result Reference Range/Units NIL 0.02 IU/mL MITOGEN-NIL 0.22 IU/mL TB-NIL <0.00 IU/mL ============================================================ Clinical Studies/Procedures/Imaging: CT Chest: [MASKED] 1. Diffuse areas of ground-glass opacity in a peribronchovascular distribution could represent an inflammatory disorder, an infectious process, or diffuse alveolar hemorrhage, depending on the clinical setting. 2. Several more nodular opacities are seen bilaterally which may represent extension of the underlying process described above, however short interval follow-up chest CT after symptoms have resolved is recommended to ensure resolution. [MASKED]: Bronch lavage: 4ml bloody fluid. Negative for malignant cells Pulmonary macrophages, epithelial cells. Some containing hemosiderin. Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o F w/ ANCA-associated vasculitis (MPA) status post induction therapy with six months of oral cyclophosphamide and prednisone and no maintenance since completing induction therapy in [MASKED] who was admitted for hemoptysis and eye redness. #MPA c/b DAH, glomerulonephritis and episcleritis: Patient initially presented to the hospital after coughing up 1.5 tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at [MASKED]. She states this is similar to her last presentation in [MASKED] with MPA c/b DAH flare. She was transferred to [MASKED] for further work up and evaluation. In terms of her MPA treatment history, patient is status post induction therapy with six months of oral cyclophosphamide and prednisone, but no maintenance since completing induction therapy in [MASKED]. She reports that she decided against maintenance therapy due to concern for hair loss and cost of the medication. Here at [MASKED], patient was diagnosed with MPA c/b diffuse alveolar hemorrhage, medial episcleritis and glomerulonephritis. Patient underwent a bronchoscopy procedure by IP which visualized large blood, cultures + for 1000/ml pseudomonas (see problem below), but no cells concerning for malignancy. The bleeding spontaneously stopped and her Hgb was stable at 10. Further labs were notable for +ANCA 1:160 titer, CRP 9.1, and normal immunoglobulin levels. She also had [MASKED] (Cr 1.3-1.4 from baseline of 1.1) with microscopy positive for RBCs and acanthocytes, diagnostic of glomerulonephritis. Patient was seen by her outpatient nephrologist Dr. [MASKED], who recommended continuing treatment per rheumatology recommendations. Patient was evaluated by ophthalmology who also deferred treatment to rheumatology for management. The rheumatology consult team recommended 3 days of pulse methylpred followed by initiation of prednisone 60mg daily to be tapered in the outpatient setting. She will take Bactrim SS daily for PCP [MASKED]. Additionally, it was recommended that patient start Qweekly Rituxan therapy for 4 weeks (day [MASKED]. Due to patient having an indeterminate quantiferon gold test in the setting of being on prednisone, the ID team recommended starting concurrent INH for 9 months. However, due to concern for side effects (i.e. neuropathy), patient declined INH treatment. A thorough discussion was held with the patient regarding the risk of developing a life-threatening active tuberculosis infection, and she fully understood these risks in making her decision. Patient will follow-up with her primary care, rheumatology and nephrology physicians as outpatient. At the time of discharge, patient was breathing comfortably on room air, with complete resolution of her eye symptoms and had a Cr of 1.4. #Pseudomonas colonization: Patient grew pseudomonas 1000/ml from bronch lavage. Per ID, likely just colonization and no need for any treatment due to it not being pathogenic. It was recommended that if patient develops a fever or symptoms of pneumonia in the outpatient setting that there be a low threshold to treat. #Hep B non-immune: Patient has a negative HBs Ag and Ab. Per patient, she has never been immunized. She has initiated rituxan therapy and would benefit from outpatient Hep B vaccination. #Anemia: Patient has a history of anemia with Hgb ~12. During this admission, she was anemic to 10 but the H/H remained stable. The new drop was likely in the setting of hemoptysis from diffuse alveolar hemorrhage. She did not need any transfusions due to blood count stability. Please follow-up regarding her anemia in the outpatient setting. #RUQ Pain: At the time of admission, patient endorsed having some RUQ pain. This quickly resolved within 2 hours and was determined by the ICU team to be secondary to vigorous coughing. Patient did not have any other abdominal pain for the remainder of her hospitalization. = ================================================================ Transitional Issues: 1. Follow-up on her MPA c/b DAH and glomerulonephritis. Patient will have Qweekly Rituxan treatment x 4weeks (week 1 was done inpatient beginning [MASKED]. Patient also discharged on 60 mg prednisone daily (to be tapered by rheumatology at outpatient follow up) and Bactrim for PCP [MASKED]. Please obtain repeat Chemistry panel on [MASKED] during outpatient appointment. 2. Follow-up regarding her Hep B non-immune status, patient would benefit from vaccination. 3. Please note per ID, due to indeterminate quant gold result while on steroids (obscures reliability of test result), patient should be on INH x 9 mo. However, after a thorough discussion with her, patient decided to decline while fully understanding the risks of developing an active TB infection while on Rituxan. Please follow-up and assess her interest in starting INH as outpatient. 4. CT chest demonstrated Several more nodular opacities are seen bilaterally which may represent extension of the underlying process (DAH). Please obtain repeat CT in 2 months per radiology. 5. Follow-up on final blood culture data (pending at time of discharge) 6. Please note patient grew pseudomonas 1000/ml from bronch lavage. Per ID, likely just colonization and no need for any treatment. If develops fever in outpatient, to have low threshold for treatment. # CODE: Full code (confirmed) # CONTACT: [MASKED], [MASKED] Medications on Admission: None Discharge Medications: 1. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth Once daily Disp #*30 Tablet Refills:*0 3. Vitamin D [MASKED] UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth Once daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Microscopic polyangiitis c/b Diffuse alveolar hemorrhage and glomerulonephritis 2. Hep B non-immune Secondary Diagnoses: 1. Anemia 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 to care for you at [MASKED] [MASKED]. You were hospitalized due to bleeding from your lung, as well as inflammation of your eye and kidneys. Due to this, you were in the intensive care unit and underwent a bronchoscopy procedure, which confirmed that you were bleeding from your lung. Your bleeding stopped on its own and you did not need any blood transfusions. The ophthalmology doctor evaluated your eye and recommended treatment based on rheumatology recommendations. The rheumatology doctors [MASKED] and recommended treating you with 3 days of IV steroids, followed by continuing prednisone 60mg daily. Since beginning steroid treatment, your eye redness improved, and you had no other episodes of bleeding. You will follow-up with Dr. [MASKED] in the outpatient setting, and she will start to taper your prednisone at that time. You will also need to take an antibiotic called Bactrim every day to prevent infections while you take the steroids. While you were here, it was also recommended that you initiate Rituxan therapy to better control your microscopic polyangiitis. This was discussed with the rheumatology doctors, infectious disease doctors [MASKED] Dr. [MASKED], [MASKED] all agreed. Your quantiferon gold test result was indeterminate. Because of this the infectious disease doctors recommended that [MASKED] start isoniazid while you are on the Rituxan. You elected to not take this medication due to potential side effects. We discussed the risks of potentially developing a life-threatening active tuberculosis infection, and you understood these considerations in reaching your decision. Please take all your medications as instructed, and follow-up with your outpatient doctors at the [MASKED] listed below. If you develop any fever, chills, shortness of breath or acute weight loss, please present to the nearest emergency room. It was a pleasure to care for you while you were here. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "D649", "Z8673" ]
[ "M317: Microscopic polyangiitis", "B1910: Unspecified viral hepatitis B without hepatic coma", "N179: Acute kidney failure, unspecified", "R042: Hemoptysis", "R739: Hyperglycemia, unspecified", "N059: Unspecified nephritic syndrome with unspecified morphologic changes", "D649: Anemia, unspecified", "H15109: Unspecified episcleritis, unspecified eye", "Z7952: Long term (current) use of systemic steroids", "Z2239: Carrier of other specified bacterial diseases", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,051,074
21,350,747
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Attending: ___. Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: ___ - cardiac catheterization with normal arteries History of Present Illness: ___ female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. Patient reports the pain awoke her from sleep this morning, sharp stabbing pain that radiated to her jaw and left shoulder. She reports associated dyspnea which is slightly worsened her baseline. She also has had multiple sets of vomiting, continues to feel nauseous. She denies fevers or recent illnesses. She denies any abdominal pain. She does report having intermittent periods of chest pain similar to this for the past several months. She also reports noting occasional blood from her ostomy. She is on Coumadin for A. fib. She presented to ___ with chest pain, ekg does not meet STEMI criteria. Global ischemia on ekg, In Afib HR 115 BP 100. Trop <0.01 at OSH. Given 5mg Lopressor on transport with brief decrease in HR to ~100, now back to 110s. Guiac positive from her ostomy was noted, and was not given heparin given therapeutic INR. The patient was then transferred to ___ for further management. Upon arrival here, ECG showed AF @ 119 with slightly improved diffuse ST depressions and STE in aVR. The patient continued to have severe chest pain and was found to be hypotensive to ___. Norepinephrine was started and aspirin 325mg was given. Labs notable for INR 2.8 and TnT 0.05, normal creatinine. During my interview with the patient, she spontaneously converted to sinus rhythm with near total resolution of ischemic ST changes on ECG. Down-titration of norepinephrine was attempted but the patient became again hypotensive to the ___ systolic, so she remained on norepninephrine 0.2mg/kg/min. With stabilization of her hemodynamics on vasopressors, her chest pain improved to ___. She denied any recent illnesses, and has not had sick contacts, productive cough, diarrhea, etc. She notes occasional scant light blood on her ostomy, but denies any frank bloody output or any other bleeding. She has not been on any long trips recently or had recent surgeries, denies other PE risk factors (and is therapeutically Anticoagulated.) On arrival to the CCU the patient was weaned off of levophed and remained in sinus rhythm. The patient had no new acute complaints. REVIEW OF SYSTEMS: Positive per HPI. Current 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. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes: YES - Hypertension: YES - Dyslipidemia: YES 2. CARDIAC HISTORY - Coronaries: Unknown - Systolic function: Unknown - Rhythm: Paroxysmal Afib with RVR OTHER PAST MEDICAL HISTORY 1. AFib on Coumadin 2. ostomy s/p diverticular resection 3. NIDDM Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Mother and brother with "heart disease". Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: reviewed in metavision GENERAL: Well developed, obese resting in bed. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unble to assess due to body habitus. 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. significant bibasilar crackles. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: cool but, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. DISHCARGE PHYSICAL EXAM: ======================== VS: 98.2, 108-128/55-68, 66-74, 18, 91-94% RA I/O: not saving urine weight 114kg GENERAL: Well developed, obese resting in bed. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unble to assess due to body habitus. CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ holosystolic murmur best auscultated at the base of the heart. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Resolution of bibasilar crackles ABDOMEN: obese, non-tender, distended. No hepatomegaly. No splenomegaly. Colostomy with erythematous skin surrounding it. Colostomy bag in place. EXTREMITIES: warm, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. Pertinent Results: ADMISSION LABS: =============== ___ 05:34PM GLUCOSE-95 UREA N-19 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 ___ 05:34PM CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-1.5* ___ 01:49PM ___ TEMP-36.4 PO2-37* PCO2-56* PH-7.32* TOTAL CO2-30 BASE XS-0 ___ 01:49PM LACTATE-1.8 ___ 01:49PM O2 SAT-63 ___ 12:13PM GLUCOSE-159* UREA N-20 CREAT-1.2* SODIUM-135 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21* ___ 12:13PM CK(CPK)-103 ___ 12:13PM CK-MB-8 cTropnT-0.24* proBNP-1459* ___ 12:13PM CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-1.5* ___ 12:13PM TSH-1.8 ___ 12:13PM WBC-13.2* RBC-4.47 HGB-13.8 HCT-42.1 MCV-94 MCH-30.9 MCHC-32.8 RDW-14.3 RDWSD-49.5* ___ 12:13PM PLT COUNT-295 ___ 12:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 12:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 12:13PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-1 ___ 12:13PM URINE GRANULAR-4* HYALINE-24* ___ 12:13PM URINE AMORPH-FEW ___ 12:13PM URINE MUCOUS-OCC ___ 08:59AM ___ PO2-42* PCO2-63* PH-7.26* TOTAL CO2-30 BASE XS-0 ___ 08:59AM O2 SAT-66 ___ 07:52AM LACTATE-2.8* ___ 07:44AM GLUCOSE-162* UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 ___ 07:44AM estGFR-Using this ___ 07:44AM cTropnT-0.05* ___ 07:44AM CK-MB-4 ___ 07:44AM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.5* ___ 07:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-7* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:44AM WBC-13.9* RBC-4.63 HGB-14.3 HCT-43.7 MCV-94 MCH-30.9 MCHC-32.7 RDW-14.4 RDWSD-49.7* ___ 07:44AM NEUTS-72.5* LYMPHS-17.1* MONOS-7.4 EOS-0.7* BASOS-0.4 IM ___ AbsNeut-10.06* AbsLymp-2.37 AbsMono-1.02* AbsEos-0.10 AbsBaso-0.05 ___ 07:44AM PLT COUNT-278 ___ 07:44AM ___ PTT-48.5* ___ MICRO: ====== **FINAL REPORT ___ Blood Culture, Routine (Final ___: WORKUP REQUESTED PER ___ ___. STAPHYLOCOCCUS EPIDERMIDIS. Isolated from only one set in the previous five days. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ON ___, 12:42PM. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. IMAGING and STUDIES ==================== TTE ___ The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 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. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, it is reasonable to consider an exercise stress test to confirm symptom status. In addition, a follow-up study is suggested in ___ months. If they are symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention is recommended. BILATERAL LENIS ___ No evidence of DVT in right or left lower extremity veins. CXR ___ IMPRESSION: 1. Cardiomegaly. 2. Engorgement of the pulmonary vasculature, concerning for mild pulmonary edema. 3. No focal consolidations to suggest pneumonia. + ECHO ___ The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 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. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. ___ Cardiac Catheterization: Intra-procedural Complications: Retained small segment of wire subcutaneously Impressions: Normal coronary arteries Moderately severe aortic stenosis - mean AVG 27 mm Hg, ___ 1.2 cm2 Mild elevation of PCW pressure 17 mm Hg Moderate elevation of PA pressure - ___ Normal cardiac index 2.8 L/min/m2 Recommendations Continued medical therapy Prevention of AF Consideration of AVR at later time if further progression Followup of retained short segment of 0.018 wire in L femoral area which is not intravascular - would require surgical retrieval which is unlikely to be necessary DISCHARGE LABS: =============== Brief Hospital Course: ___ female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. She was found to be in a fib with RVR, and have and NSTEMI. She was also found to have a staph epidermidis bacteremia. # Acute on chronic diastolic heart failure Patient presented as transfer from ___ with afib with RVR with diffuse downsloping ST depressions and ST elevation in aVR and chest pain. On arrival to ___ ED, EKG with Afib with RVR and rates to 119 with slighty improved ST depressions and STE in aVR. Echo with an EF of 55% and aortic stenosis. Levophed was started given hypotension ___. She spontaneously converted to sinus rthym in the ED with near total resolution of ischemic changes on EKG. Levophed was unable to be weaned in ED and patient remained on Levophed for several days in the CCU. BNP ~1500 with mild pulmonary edema on CXR. TTE with severe aortic stenosis. Do not suspect obstructive (PE) given therapeutic INR and negative LENIS. The patient was initially diuresed with IV Lasix, and transitioned to PO Lasix 40mg daily several days before discharge. Her metoprolol was held initially, and then gradually titrated back to her home dose of Metoprolol XL 100mg. Her lisinopril was discontinued since she did not have evidence of systolic heart failure on echo. #Septic Shock # Staph Epidermidis Bacteremia: On ___, two out of two bottles of blood cultures grew what turned out to be staph epidermidis. Although this is usually a contaminant, the medical team thought that this may have precipitated the afib with RVR. It may be iatrogenic, from the central line that was inserted at the OSH, or from the skin breakdown around her ostomy. She was started on IV vancomycin on ___, and she will need to complete a 14 day course of antibiotics, through ___. # Atrial Fibrillation with RVR: Precipitant likely bacteremia. Patient reports episodes of palpitations intermittently, and spontaneously converted to sinus rhythm. Her Chads-Vasc Sore is 5. An extensive conversation was had about starting apixaban, but the patient did not want to start it at this time. She was discharged on her home warfarin with a Lovenox bridge given a subtherapeutic INR. Her metoprolol was continued for rate control once blood pressures increased. # NTEMI. Likely demand. Coronary arteries on cardiac catheterization without evidence of atherosclerosis. ASA was stopped on ___. Her simvastatin was changed to Atorvastatin 80mg given her high ASCVD risk score. # Moderate Aortic Stenosis Severe aortic stenosis was noted on TTE ___, but the cardiac catheterization on ___ suggested moderate AS. Patient was not symptomatic. Her aortic stenosis should be monitored and she should be considered for further management if she becomes symptomatic. #Acute kidney Injury: Likely ___ to ATN from hypotension. Cr was 0.7 at time of dischare. CHRONIC ISSUES ============== # HLD: Patient was started on atorvastatin 80 mg daily in light of high ASCVD risk score. # HTN: HCTZ and Lisinopril held because of normotension. Maintained on home Metoprolol. Started on PO Lasix 40mg daily. # NIDDM: Metformin was held and the patient was on an insulin sliding scale. # Chronic Back Pain: Continued tramadol. Held naproxen in the setting of possible intervention. TRANSITIONAL ISSUES =================== [] Complication during procedure: guidewire broke, and is in soft tissue of groin. Monitor for signs of infection. [] Patient was discharged to complete a 14 day course of vancomycin 1500mg IV Q12H for coag negative staph bacteremia (last day ___ [] Patient was discharged on enoxaparin bridge to warfarin. The patient will go to her PCP's office to have her INR drawn on ___. Once INR > 2.0, enoxaparin should be stopped. [] Patient was discharged on Lasix 40mg daily due to volume overload. Her weight should be monitored, and her kidney function and electrolytes should be checked at her next appointment. [] Patient's anti lipid therapy was switched from simvastatin 5mg to atorvastatin 80mg. [] Patient was normotensive while in the hospital. Her lisinopril and HCTZ were held at time of discharge, and could be restarted in the outpatient setting if needed. [] Patient was discharged with hydrocortisone cream for ___ irritation. [] Please assist patient with smoking cessation. # CODE: Full # CONTACT/HCP: ___ (Husband) verbally designated HCP: ___ # DRY WEIGHT: Unknown # Discharge weight: 114kg Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Naproxen 500 mg PO Q8H:PRN Pain - Mild 7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 8. Simvastatin 5 mg PO QPM 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 10. Warfarin 8 mg PO DAILY16 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 12. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Enoxaparin Sodium 110 mg SC BID RX *enoxaparin 100 mg/mL 110 mg/mL INJ twice a day Disp #*14 Syringe Refills:*0 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Hydrocortisone Cream 1% 1 Appl TP QID ___ irritation RX *hydrocortisone 1 % apply small amount around the ostomy site four times a day Refills:*0 5. Vancomycin 1500 mg IV Q 12H RX *vancomycin 1 gram 1.5 g IV twice a day Disp #*22 Vial Refills:*0 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. Levothyroxine Sodium 50 mcg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Naproxen 500 mg PO Q8H:PRN Pain - Mild 11. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN wheezing 12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 13. umeclidinium 62.5 mcg/actuation inhalation DAILY 14. Warfarin 8 mg PO DAILY16 15.Outpatient Lab Work Please draw a ___, and fax results to ___ ATTN: ___ ICD10: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: - Cardiogenic shock - Acute on chronic diastolic heart failure Secondary Diagnoses: - NSTEMI - Moderate Aortic Stenosis - Coagulase Negative Staph bacteremia - Atrial Fibrillation with RVR - Acute kidney injury - Hyperlipidemia - Hypertension - Non-insulin dependent diabetes mellitus - Chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to be a part of your care team at ___ ___. Why did you come to the hospital? ================================= - You came to the hospital with chest pain, trouble breathing, and nausea. You were transferred to ___ for further workup for your heart. What did we do for you? ======================= - You were found to have a rapid, irregular heartrate called atrial fibrillation. - We think this atrial fibrillation was triggered by an infection in your blood stream. - We started you on strong antibiotics for an infection in your blood stream (vancomycin). What do you need to do? ======================= - It is important that you follow up with a Cardiologist (appointment information below) - It is important that you continue your vancomycin antibiotic infusions twice per day up through and including ___. - MEDICATION CHANGES: -- STOP taking simvastatin. START taking Atorvastatin 80 mg daily. -- STOP taking lisinopril -- CONTINUE taking warfarin 8mg per day. START Lovenox injections twice per day until your INR is greater than 2. Follow up with your ___ clinic for INR monitoring. It was a pleasure caring for you. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___
[ "I214", "R6521", "A411", "N170", "I5033", "T82518A", "I248", "I350", "I110", "I480", "Z7901", "Z7902", "Z933", "R195", "Z720", "E119", "E785", "M549", "G8929", "Y840", "Y92238" ]
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: [MASKED] - cardiac catheterization with normal arteries History of Present Illness: [MASKED] female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. Patient reports the pain awoke her from sleep this morning, sharp stabbing pain that radiated to her jaw and left shoulder. She reports associated dyspnea which is slightly worsened her baseline. She also has had multiple sets of vomiting, continues to feel nauseous. She denies fevers or recent illnesses. She denies any abdominal pain. She does report having intermittent periods of chest pain similar to this for the past several months. She also reports noting occasional blood from her ostomy. She is on Coumadin for A. fib. She presented to [MASKED] with chest pain, ekg does not meet STEMI criteria. Global ischemia on ekg, In Afib HR 115 BP 100. Trop <0.01 at OSH. Given 5mg Lopressor on transport with brief decrease in HR to ~100, now back to 110s. Guiac positive from her ostomy was noted, and was not given heparin given therapeutic INR. The patient was then transferred to [MASKED] for further management. Upon arrival here, ECG showed AF @ 119 with slightly improved diffuse ST depressions and STE in aVR. The patient continued to have severe chest pain and was found to be hypotensive to [MASKED]. Norepinephrine was started and aspirin 325mg was given. Labs notable for INR 2.8 and TnT 0.05, normal creatinine. During my interview with the patient, she spontaneously converted to sinus rhythm with near total resolution of ischemic ST changes on ECG. Down-titration of norepinephrine was attempted but the patient became again hypotensive to the [MASKED] systolic, so she remained on norepninephrine 0.2mg/kg/min. With stabilization of her hemodynamics on vasopressors, her chest pain improved to [MASKED]. She denied any recent illnesses, and has not had sick contacts, productive cough, diarrhea, etc. She notes occasional scant light blood on her ostomy, but denies any frank bloody output or any other bleeding. She has not been on any long trips recently or had recent surgeries, denies other PE risk factors (and is therapeutically Anticoagulated.) On arrival to the CCU the patient was weaned off of levophed and remained in sinus rhythm. The patient had no new acute complaints. REVIEW OF SYSTEMS: Positive per HPI. Current 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. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes: YES - Hypertension: YES - Dyslipidemia: YES 2. CARDIAC HISTORY - Coronaries: Unknown - Systolic function: Unknown - Rhythm: Paroxysmal Afib with RVR OTHER PAST MEDICAL HISTORY 1. AFib on Coumadin 2. ostomy s/p diverticular resection 3. NIDDM Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Mother and brother with "heart disease". Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: reviewed in metavision GENERAL: Well developed, obese resting in bed. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unble to assess due to body habitus. 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. significant bibasilar crackles. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: cool but, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. DISHCARGE PHYSICAL EXAM: ======================== VS: 98.2, 108-128/55-68, 66-74, 18, 91-94% RA I/O: not saving urine weight 114kg GENERAL: Well developed, obese resting in bed. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unble to assess due to body habitus. CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] holosystolic murmur best auscultated at the base of the heart. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Resolution of bibasilar crackles ABDOMEN: obese, non-tender, distended. No hepatomegaly. No splenomegaly. Colostomy with erythematous skin surrounding it. Colostomy bag in place. EXTREMITIES: warm, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:34PM GLUCOSE-95 UREA N-19 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [MASKED] 05:34PM CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-1.5* [MASKED] 01:49PM [MASKED] TEMP-36.4 PO2-37* PCO2-56* PH-7.32* TOTAL CO2-30 BASE XS-0 [MASKED] 01:49PM LACTATE-1.8 [MASKED] 01:49PM O2 SAT-63 [MASKED] 12:13PM GLUCOSE-159* UREA N-20 CREAT-1.2* SODIUM-135 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21* [MASKED] 12:13PM CK(CPK)-103 [MASKED] 12:13PM CK-MB-8 cTropnT-0.24* proBNP-1459* [MASKED] 12:13PM CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-1.5* [MASKED] 12:13PM TSH-1.8 [MASKED] 12:13PM WBC-13.2* RBC-4.47 HGB-13.8 HCT-42.1 MCV-94 MCH-30.9 MCHC-32.8 RDW-14.3 RDWSD-49.5* [MASKED] 12:13PM PLT COUNT-295 [MASKED] 12:13PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 12:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 12:13PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-1 [MASKED] 12:13PM URINE GRANULAR-4* HYALINE-24* [MASKED] 12:13PM URINE AMORPH-FEW [MASKED] 12:13PM URINE MUCOUS-OCC [MASKED] 08:59AM [MASKED] PO2-42* PCO2-63* PH-7.26* TOTAL CO2-30 BASE XS-0 [MASKED] 08:59AM O2 SAT-66 [MASKED] 07:52AM LACTATE-2.8* [MASKED] 07:44AM GLUCOSE-162* UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 [MASKED] 07:44AM estGFR-Using this [MASKED] 07:44AM cTropnT-0.05* [MASKED] 07:44AM CK-MB-4 [MASKED] 07:44AM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.5* [MASKED] 07:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-7* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 07:44AM WBC-13.9* RBC-4.63 HGB-14.3 HCT-43.7 MCV-94 MCH-30.9 MCHC-32.7 RDW-14.4 RDWSD-49.7* [MASKED] 07:44AM NEUTS-72.5* LYMPHS-17.1* MONOS-7.4 EOS-0.7* BASOS-0.4 IM [MASKED] AbsNeut-10.06* AbsLymp-2.37 AbsMono-1.02* AbsEos-0.10 AbsBaso-0.05 [MASKED] 07:44AM PLT COUNT-278 [MASKED] 07:44AM [MASKED] PTT-48.5* [MASKED] MICRO: ====== **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: WORKUP REQUESTED PER [MASKED] [MASKED]. STAPHYLOCOCCUS EPIDERMIDIS. Isolated from only one set in the previous five days. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPHYLOCOCCUS EPIDERMIDIS | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [MASKED] ON [MASKED], 12:42PM. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CLUSTERS. IMAGING and STUDIES ==================== TTE [MASKED] The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 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. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on [MASKED] ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, it is reasonable to consider an exercise stress test to confirm symptom status. In addition, a follow-up study is suggested in [MASKED] months. If they are symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention is recommended. BILATERAL LENIS [MASKED] No evidence of DVT in right or left lower extremity veins. CXR [MASKED] IMPRESSION: 1. Cardiomegaly. 2. Engorgement of the pulmonary vasculature, concerning for mild pulmonary edema. 3. No focal consolidations to suggest pneumonia. + ECHO [MASKED] The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 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. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. [MASKED] Cardiac Catheterization: Intra-procedural Complications: Retained small segment of wire subcutaneously Impressions: Normal coronary arteries Moderately severe aortic stenosis - mean AVG 27 mm Hg, [MASKED] 1.2 cm2 Mild elevation of PCW pressure 17 mm Hg Moderate elevation of PA pressure - [MASKED] Normal cardiac index 2.8 L/min/m2 Recommendations Continued medical therapy Prevention of AF Consideration of AVR at later time if further progression Followup of retained short segment of 0.018 wire in L femoral area which is not intravascular - would require surgical retrieval which is unlikely to be necessary DISCHARGE LABS: =============== Brief Hospital Course: [MASKED] female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. She was found to be in a fib with RVR, and have and NSTEMI. She was also found to have a staph epidermidis bacteremia. # Acute on chronic diastolic heart failure Patient presented as transfer from [MASKED] with afib with RVR with diffuse downsloping ST depressions and ST elevation in aVR and chest pain. On arrival to [MASKED] ED, EKG with Afib with RVR and rates to 119 with slighty improved ST depressions and STE in aVR. Echo with an EF of 55% and aortic stenosis. Levophed was started given hypotension [MASKED]. She spontaneously converted to sinus rthym in the ED with near total resolution of ischemic changes on EKG. Levophed was unable to be weaned in ED and patient remained on Levophed for several days in the CCU. BNP ~1500 with mild pulmonary edema on CXR. TTE with severe aortic stenosis. Do not suspect obstructive (PE) given therapeutic INR and negative LENIS. The patient was initially diuresed with IV Lasix, and transitioned to PO Lasix 40mg daily several days before discharge. Her metoprolol was held initially, and then gradually titrated back to her home dose of Metoprolol XL 100mg. Her lisinopril was discontinued since she did not have evidence of systolic heart failure on echo. #Septic Shock # Staph Epidermidis Bacteremia: On [MASKED], two out of two bottles of blood cultures grew what turned out to be staph epidermidis. Although this is usually a contaminant, the medical team thought that this may have precipitated the afib with RVR. It may be iatrogenic, from the central line that was inserted at the OSH, or from the skin breakdown around her ostomy. She was started on IV vancomycin on [MASKED], and she will need to complete a 14 day course of antibiotics, through [MASKED]. # Atrial Fibrillation with RVR: Precipitant likely bacteremia. Patient reports episodes of palpitations intermittently, and spontaneously converted to sinus rhythm. Her Chads-Vasc Sore is 5. An extensive conversation was had about starting apixaban, but the patient did not want to start it at this time. She was discharged on her home warfarin with a Lovenox bridge given a subtherapeutic INR. Her metoprolol was continued for rate control once blood pressures increased. # NTEMI. Likely demand. Coronary arteries on cardiac catheterization without evidence of atherosclerosis. ASA was stopped on [MASKED]. Her simvastatin was changed to Atorvastatin 80mg given her high ASCVD risk score. # Moderate Aortic Stenosis Severe aortic stenosis was noted on TTE [MASKED], but the cardiac catheterization on [MASKED] suggested moderate AS. Patient was not symptomatic. Her aortic stenosis should be monitored and she should be considered for further management if she becomes symptomatic. #Acute kidney Injury: Likely [MASKED] to ATN from hypotension. Cr was 0.7 at time of dischare. CHRONIC ISSUES ============== # HLD: Patient was started on atorvastatin 80 mg daily in light of high ASCVD risk score. # HTN: HCTZ and Lisinopril held because of normotension. Maintained on home Metoprolol. Started on PO Lasix 40mg daily. # NIDDM: Metformin was held and the patient was on an insulin sliding scale. # Chronic Back Pain: Continued tramadol. Held naproxen in the setting of possible intervention. TRANSITIONAL ISSUES =================== [] Complication during procedure: guidewire broke, and is in soft tissue of groin. Monitor for signs of infection. [] Patient was discharged to complete a 14 day course of vancomycin 1500mg IV Q12H for coag negative staph bacteremia (last day [MASKED] [] Patient was discharged on enoxaparin bridge to warfarin. The patient will go to her PCP's office to have her INR drawn on [MASKED]. Once INR > 2.0, enoxaparin should be stopped. [] Patient was discharged on Lasix 40mg daily due to volume overload. Her weight should be monitored, and her kidney function and electrolytes should be checked at her next appointment. [] Patient's anti lipid therapy was switched from simvastatin 5mg to atorvastatin 80mg. [] Patient was normotensive while in the hospital. Her lisinopril and HCTZ were held at time of discharge, and could be restarted in the outpatient setting if needed. [] Patient was discharged with hydrocortisone cream for [MASKED] irritation. [] Please assist patient with smoking cessation. # CODE: Full # CONTACT/HCP: [MASKED] (Husband) verbally designated HCP: [MASKED] # DRY WEIGHT: Unknown # Discharge weight: 114kg Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Naproxen 500 mg PO Q8H:PRN Pain - Mild 7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 8. Simvastatin 5 mg PO QPM 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 10. Warfarin 8 mg PO DAILY16 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 12. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Enoxaparin Sodium 110 mg SC BID RX *enoxaparin 100 mg/mL 110 mg/mL INJ twice a day Disp #*14 Syringe Refills:*0 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Hydrocortisone Cream 1% 1 Appl TP QID [MASKED] irritation RX *hydrocortisone 1 % apply small amount around the ostomy site four times a day Refills:*0 5. Vancomycin 1500 mg IV Q 12H RX *vancomycin 1 gram 1.5 g IV twice a day Disp #*22 Vial Refills:*0 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. Levothyroxine Sodium 50 mcg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Naproxen 500 mg PO Q8H:PRN Pain - Mild 11. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN wheezing 12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 13. umeclidinium 62.5 mcg/actuation inhalation DAILY 14. Warfarin 8 mg PO DAILY16 15.Outpatient Lab Work Please draw a [MASKED], and fax results to [MASKED] ATTN: [MASKED] ICD10: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: - Cardiogenic shock - Acute on chronic diastolic heart failure Secondary Diagnoses: - NSTEMI - Moderate Aortic Stenosis - Coagulase Negative Staph bacteremia - Atrial Fibrillation with RVR - Acute kidney injury - Hyperlipidemia - Hypertension - Non-insulin dependent diabetes mellitus - Chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to be a part of your care team at [MASKED] [MASKED]. Why did you come to the hospital? ================================= - You came to the hospital with chest pain, trouble breathing, and nausea. You were transferred to [MASKED] for further workup for your heart. What did we do for you? ======================= - You were found to have a rapid, irregular heartrate called atrial fibrillation. - We think this atrial fibrillation was triggered by an infection in your blood stream. - We started you on strong antibiotics for an infection in your blood stream (vancomycin). What do you need to do? ======================= - It is important that you follow up with a Cardiologist (appointment information below) - It is important that you continue your vancomycin antibiotic infusions twice per day up through and including [MASKED]. - MEDICATION CHANGES: -- STOP taking simvastatin. START taking Atorvastatin 80 mg daily. -- STOP taking lisinopril -- CONTINUE taking warfarin 8mg per day. START Lovenox injections twice per day until your INR is greater than 2. Follow up with your [MASKED] clinic for INR monitoring. It was a pleasure caring for you. We wish you the best! Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "I110", "I480", "Z7901", "Z7902", "E119", "E785", "G8929" ]
[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "R6521: Severe sepsis with septic shock", "A411: Sepsis due to other specified staphylococcus", "N170: Acute kidney failure with tubular necrosis", "I5033: Acute on chronic diastolic (congestive) heart failure", "T82518A: Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter", "I248: Other forms of acute ischemic heart disease", "I350: Nonrheumatic aortic (valve) stenosis", "I110: Hypertensive heart disease with heart failure", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z933: Colostomy status", "R195: Other fecal abnormalities", "Z720: Tobacco use", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "M549: Dorsalgia, unspecified", "G8929: Other chronic pain", "Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]
10,051,074
27,940,505
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Attending: ___. Chief Complaint: Severe Aortic Stenosis Major Surgical or Invasive Procedure: TAVR attempt ___ complicated by hematoma TAVR ___ PPM attempt ___ complicated by RA/RV perforation and cardiac tamponade Mediastinal exploration w/sternotomy ___ External pacing wire and pacer Insertion of permanent pacemaker ___ History of Present Illness: ___ y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, who was admitted on ___ for TAVR. She was previously admitted to the CCU in ___ for AFib with RVR in the setting of an NSTEMI and staph epidermidis bacteremia. An echocardiogram at this time showed moderate/severe aortic stenosis. Cardiac cath revealed normal coronary arteries, moderate/severe aortic stenosis - mean AVG 27 mm Hg, ___ 1.2 cm2, mild elevation of PCW pressure 17 mm Hg and moderate elevation of PA pressure - 59/25. On this admission, the patient endorsed SOB with minimal exertion, intermittent palpitations, and constant ___ edema. She denied syncope, chest pain, and orthopnea. TAVR was attempted on ___, but the procedure was aborted due to Proglide misfiring during PreClose of the right remoral artery, which led to development of a moderate hematoma of the right groin. The hematoma remained soft after 30 minutes hemostasis, and the patient remained hemodynamically stable. She was transferred to the CCU for further management until TAVR could be rescheduled. On arrival to the CCU, patient was intubated with vitals of BP 130/48 HR 49 RR 13 O2 Sat 100% on volume-controlled vent. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF (EF > 55%) - Paroxysmal AFib - NSTEMI ___ 3. OTHER PAST MEDICAL HISTORY Ostomy s/p diverticular resection COPD Hypothyroidism Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ON ADMISSION Vitals: 97.5, 110/71, 69, 94% RA General: Sitting up in bed. No acute distress. Neuro: Alert and oriented x3, speech is clear. MAE. No focal deficits. CV: RRR. + harsh systolic murmur heard at ___ left and right sternal borders radiating to carotids. Pulm: Regular, tachypenic, diminished. Abd: Soft, obesely distended with redundant panus, non-tender to palpation. Ext: Warm and well-perfused. +2 ___ bilat. Mild/mod bilat ___ edema. AT DISCHARGE VS: T 97.9 HR 63 RR 18 BP 102/63 96%2LNC General: sitting up in bed, fatigued Neuro: A&Ox3, NAD, speech clear, no focal deficits. very deconditioned, needs help to sit upright CV: RRR no m/r/g heard Chest: CTAB Abd: obese with redundant panus, colostomy bag in place with stool, patent, +BS, NT Ext: warm and well perfused, +2 ___, mild BLE edema Pertinent Results: ADMISSION LABS: ___ 06:48PM GLUCOSE-93 UREA N-14 CREAT-1.1 SODIUM-142 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18 ___ 06:48PM estGFR-Using this ___ 06:48PM ALT(SGPT)-17 AST(SGOT)-22 CK(CPK)-75 ALK PHOS-80 TOT BILI-0.5 ___:48PM proBNP-310 ___ 06:48PM ALBUMIN-4.1 ___ 06:48PM TSH-1.7 ___ 06:48PM WBC-8.0 RBC-4.01 HGB-11.7 HCT-36.1 MCV-90 MCH-29.2 MCHC-32.4 RDW-14.7 RDWSD-49.1* ___ 06:48PM PLT COUNT-226 ___ 06:48PM ___ PTT-29.2 ___ TTE ___ Prevalve deployment No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. ___ was notified in person of the results on ___ at 1345 Postvalve deployment Evolut valve seen in the aortic position. It appears well seated. There is trival central and perivalvular regurgitation seen. Moderate mitral regurgitation seen. Aorta intact. DISCHARGE LABS: ___ 12:19AM BLOOD Hct-29.1* ___ 12:19AM BLOOD ___ ___ 05:50AM BLOOD Glucose-88 UreaN-26* Creat-1.6* Na-137 K-4.5 Cl-92* HCO3-30 AnGap-15 ___ 05:50AM BLOOD Calcium-7.6* Phos-3.1 Mg-2.0 LFT TREND: ___ 05:50AM BLOOD ALT-134* AST-55* ___ 05:11AM BLOOD ALT-259* AST-53* AlkPhos-152* TotBili-1.8* ___ 05:05AM BLOOD ALT-569* AST-122* LD(___)-337* AlkPhos-191* TotBili-2.1* ___ 04:51AM BLOOD ALT-853* AST-240* LD(LDH)-358* AlkPhos-201* TotBili-2.1* ___ 04:48AM BLOOD ALT-1294* AST-556* AlkPhos-209* TotBili-2.2* ___ 01:29AM BLOOD ALT-2279* AST-1840* LD(___)-625* AlkPhos-224* Amylase-29 TotBili-2.4* ___ 07:44AM BLOOD ALT-2883* AST-3645* AlkPhos-216* Amylase-34 TotBili-2.9* ___ 01:37AM BLOOD ALT-170* AST-462* LD(LDH)-595* AlkPhos-149* TotBili-2.0* ___ 11:14PM BLOOD ALT-34 AST-38 LD(LDH)-338* AlkPhos-74 TotBili-0.7 ___ 06:48PM BLOOD ALT-17 AST-22 CK(CPK)-75 AlkPhos-80 TotBili-0.5 PERMANENT PACEMAKER INFO: Device Generator S/L # Model # Description Manufact Implanted explantDate Status ___ Pacemaker Adapta L ___ ADDRL1 ___ ___ Implanted Leads Loc S/L # Model # Description Manufact Implanted explantDate Status Other ___ Capsure EPI 4968 60cm ___ ___ Prev. Implanted Other ___ Capsure EPI ___ 60cm ___ ___ Prev. Implanted EMR 000___-M Name: ___ ID: ___ Study Date: ___ 15:40:00 p. ___ Settings Date tested: ___ Generator Mode switch rate Off/NA@ Hysteresis Off/NA Rate Responsive Off/NA Measurements Atrial RV LV SVC/RV Amplitude 5.6mV 11.0mV Pacing impedance 605&#937; 746&#937; Pacing threshold 1.75V 1.75V Threshold pulse width 0.4ms 0.4ms End Procedure Patient status is stable. The distal pulses are unchanged from pre procedure. At the end of the case, the tempoary wire was removed. The patient was transferred to the recovery area. Verbal and written instructions were given to the patient. Verbalizes or communicates understanding of post-procedure instructions. The patient was transported to the holding area in stable condition. Patient transferred to a bed using a slide board. Estimated blood loss during the procedure was 0 mL. No specimen was sent to pathology. Patient status is stable. Skin assessment unchanged from start of case. The distal pulses are unchanged from pre procedure. The IV site is unchanged from the start of the case. The patient was transported to the holding area in stable condition. Patient transferred to a bed using a slide board. All inventory items have been scanned. Radiologic A plane fluoro time 0.6 min B plane fluoro time 0 min Total rads A plane 4 mGy Total rads B plane 0 mGy Conclusion • Successful dual chamber pacemaker generator implant to pre-existing epicardial RA/RV leads. • There were no complications. Brief Hospital Course: ___ y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, who was admitted for TAVR, which was attempted and aborted due to ProGlide misfiring and subsequent hematoma of the right groin. # CORONARIES: no CAD # PUMP: EF >55% # RHYTHM: nsr ACUTE ISSUES # Severe Aortic Stenosis: Patient was admitted for TAVR of her stenosed aortic valve. TAVR was aborted due to complication secondary to difficult vascular access with a hematoma. She underwent TAVR ___, which was complicated by complete heart block, requiring placement of a temporary pacemaker. She was subsequently monitored in the CCU and was hemodynamically stable, extubated ___, and called out to the Cardiology floor on ___. Pacemaker insertion was attempted on ___ but was complicated by RV perforation (see below) Following recovery from this complication, she was monitored in the ICU and continued diuresis with pericardial drain and transferred out to the regular floor. She continued with diuresis. She declined physical therapy on ___ due to fatigue following her pacemaker but due to her course will require a good deal of therapy to mobilize and increase strength for out of bed activities. Her foley was discontinued on the day of discharge. She will follow up with both Dr. ___ Cardiac ___ for her sternotomy wound as well as her Structural Heart follow up appt. (see DC worksheet) #Complete Heart Block: The patient's TAVR ___ was complicated by complete heart block. She was initially placed on a temporary screw-in pacemaker and monitored in the CCU. EP was consulted and recommended permanent pacemaker placement, which was done ___. Elective permanent pacemaker placement was attempted on ___, but during positioning of the RV lead, the patient became hypotensive and unresponsive, and was found to have RV perforation. (see below) She ultimately underwent placement of the permanent pacemaker (right sided) on ___ without complication. She will continue oral antibiotics (Clindamycin 450 mg every 8 hours for 5 days, having received her first dose prior to discharge from ___ for surgical prophylaxis following permanent pacemaker insertion. She should take an oral probiotic such as Lactobacillus for 2 weeks, and foods with active cultures such as yogurt and cottage cheese to prevent antibiotic diarrhea. #RV perforation She was found to have a perforation of the RV apex during pacemaker placement attempt on ___. A pericardial drain was placed for tamponade and initially yielded 420cc of fluid (minimal output since). She sustained cardiac arrest but after 1 min of chest compressions, ROSC was achieved. She was intubated for agonal breathing and transferred to the CCU for further management. The PPM was not placed at this time. On ___, she went for sternotomy, RA/RV repair, and epicardial leads with Cardiac surgery, and was transferred to C-Surg service. The permanent pacemaker was ultimately placed without issues on ___. She will follow up with Device Clinic in one week for wound check and device interrogation. # Hematoma s/p attempted TAVR for severe aortic stenosis: Patient developed a right groin hematoma following a complication while attempting to attain vascular access for TAVR. She remained hemodynamically stable after hemostasis, and did not require blood transfusion. She was extubated on post-procedure day #1, and ultrasound of the right groin showed no evidence of pseudoaneurysm or AV fistula of the right groin. The procedure was then successfully re-attempted on ___ (see above). #Anemia: The patient's Hgb dropped to 6.7 after TAVR placement. Minimal blood loss was reported during the procedure. She was transfused 2 units of pRBCs, with an appropriate response in Hgb. On ___ she received another 1U PRBC with again appropriate response. She received 2 units ___ and one unit ___ with appropriate response, her Hct on the day of discharge was 29.1. # Paroxysmal AFib: The patient had had multiple previous admissions for AFib with RVR. Her Amiodarone dose was doubled (200 -> 400 mg daily) on discharge from ___ on ___. From reviewing their notes, it was unclear if the intended discharge dose was 400 daily or 400 BID. She was resumed on amiodarone 400 daily while in the hospital, then ultimately down to 200mg daily after discussing with multiple teams. Her home warfarin 6mg PO daily was held due to her hematoma. She remained in sinus rhythm while in the CCU. The Coumadin was resumed several days later when stable and her INR was 2.1 on the day of discharge. Her Diltiazem was discontinued. Her PCP should resume management of her Coumadin at discharge from rehab. Her Coumadin should be dosed 1 to 5 mg Daily to achieve an INR of 2 to 3.0. CHRONIC ISSUES # Chronic HFpEF Secondary to Severe Aortic Stenosis: There was no evidence of acute volume overload on exam during her inpatient stay. Her home Furosemide 40 mg PO DAILY was held given concern for hypovolemia with hemorrhage after the aborted TAVR procedure. # T2DM: The patient's home MetFORMIN XR (Glucophage XR) 1000 mg PO BID was held, and the patient was kept on Insulin Sliding Scale as an inpatient. The Metformin should continue to be held until her creatinine normalizes to her baseline (1.1 to 1.2) after which her Lantus can be discontinued. We recommend continuing a sliding scale until her metabolism is more stable and her glucose remains stable on before meal and QHS checks. # HLD: The patient's home Atorvastatin 80 mg PO QPM was decreased to 40mg daily due to concern for drug-drug interaction with Amiodarone. # Hypothyroidism: The patient was continued on home Levothyroxine Sodium 50 mcg PO DAILY. # COPD: The patient's home Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob was held, as it was non-formulary. She was placed on an albuterol inhaler Q6hrs while intubated after the aborted TAVR. The patient's home umeclidinium 62.5 mcg/actuation inhalation DAILY was held, as it was also non-formulary. She can resume these at rehab if on formulary. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. umeclidinium 62.5 mcg/actuation inhalation DAILY 2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 3. Diltiazem 30 mg PO TID 4. Amiodarone 400 mg PO BID 5. Warfarin 6 mg PO DAILY16 6. Atorvastatin 80 mg PO QPM 7. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 8. Furosemide 40 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Aspirin EC 81 mg PO DAILY 3. Clindamycin 450 mg PO Q8H Duration: 5 Days Continue for 5 days. First dose given prior to discharge from ___ 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. Lidocaine 5% Patch 2 PTCH TD QPM 12 hrs on, 12 hrs off remove at night 6. Miconazole 2% Cream 1 Appl TP BID to under bilateral breasts 7. Miconazole Powder 2% 1 Appl TP BID:PRN to groin 8. Milk of Magnesia 30 mL PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Amiodarone 200 mg PO DAILY 12. Atorvastatin 40 mg PO QPM 13. Furosemide 80 mg PO DAILY 14. Warfarin ___ mg PO DAILY16 atrial fibrillation for INR goal 2 to 3 Take 5 mg ___, ck. INR ___. Cyanocobalamin 1000 mcg PO DAILY 16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 17. Levothyroxine Sodium 50 mcg PO DAILY 18. umeclidinium 62.5 mcg/actuation inhalation DAILY 19. Lactobacillus Twice Daily (or Florastor 100 mg BID) 20. HELD- MetFORMIN XR (Glucophage XR) 1000 mg PO BID This medication was held. Do not restart MetFORMIN XR (Glucophage XR) until Creatinine at baseline 1.1-1.2 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Severe Aortic Stenosis complete heart block hematoma during first TAVR attempt ___ RV perforation during attempted ___ insertion ___ insertion ___ COPD PAF on amiodarone and Coumadin acute on chronic diastolic heart failure acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a procedure to help fix your mitral valve narrowing which was causing shortness of breath and weight gain. We were unable to perform the TAVR procedure on the first try because you started bleeding in your right groin area. We stopped the bleeding and then proceeded with TAVR on ___ with the help of cardiac surgery. You had developed a hematoma during the first attempt of the TAVR and were seen by Vascular Surgery. You developed trouble with the electrical system in the heart after the TAVR and we attempted to place a pacemaker on ___ but had complications due to an RA/RV perforation and acute cardiac tamponade. A drain was placed and you had chest compressions. A temporary pacing wire was placed. You were monitored and cared for closely in the ICU. You continued to be diuresed with Lasix for weight gain and fluid due to your heart failure and underlying cardiac condition. You were transferred to the general floor on ___. You continued with a temporary pacing wire and external pacemaker until ___ when it was inserted on the right side. There were no complications with the procedure. You will continue with oral antibiotics (Clindamycin 450 mg every 8 hours for 5 days) as prophylaxis to prevent infection at the pacemaker site. Increase intake of foods with probiotics (yogurt, cottage cheeses) and a probiotic such as Lactobacillus for 2 weeks to prevent antibiotic associated diarrhea. Due to your prolonged stay and complications, you have become more deconditioned and had minimal progress with physical therapy due to the pacemaker issues. You should continue to work with out of bed activity, increasing strength, be out of bed for meals and using a commode. Your foley catheter was discontinued on the day of discharge due to risk of infection and you will be due to void 8 hours following discontinuance of the catheter. A urine analysis should be sent at the time of the second void to ensure you do not have a urinary tract infection since the catheter was indwelling for several days. You should be using an incentive spirometer, doing deep breathing and be out of bed regularly to increase strength, endurance and to prevent pneumonia from prolonged bed rest during your recovery. Your Coumadin was stopped prior to the procedures and because of bleeding issues. It was restarted once you were out of the ICU and should be followed by your PCP after discharge from rehab. Your INR goal is 2 to 3. Your INR at discharge was 2.1 on the day of discharge. You will continue with a low dose Aspirin 81 mg Daily to prevent blood clots in your new valve, along with your chronic Coumadin for your AFIB. You should continue to follow a low sodium (2 grams daily) and limit fluids to 1.5 liters daily. You should be weighed daily, preferably on a standing scale for accuracy, with close monitoring of intake and output. If you have increase in weight, your Lasix dose may need to be adjusted. Prior to discharge, you were on 40 mg IV Lasix twice daily, and were changed to 80 mg Daily at discharge. You received 40 mg IV on the morning of discharge and 80 mg PO at the time of discharge. You should resume 80 mg orally in the morning on ___. Your Amiodarone was decreased to 200 mg a day to help prevent atrial fibrillation. Your Atorvastatin was decreased to 40 mg to minimize reactions from other medications such as Amiodarone. You will follow up in Device Clinic in one week for a wound check and device interrogation for your pacemaker. You will follow up with Structural Heart (appt. information below) and Dr. ___ Cardiac ___ for a wound check. Your Structural Heart appointment will be rescheduled for that same day and your echocardiogram will be done on that day as well. Your rehab should be contacted with this appointment information directly. If they do not receive a call in ___ business days, contact ___ to confirm the date and time. Your Metformin was held due to a rising creatinine and you were placed on a sliding scale insulin and Lantus. When your creatinine returns to normal (1.1 to 1.2) you can resume Metformin and discontinue the Lantus. Your glucose should be monitored and continue a heart healthy carb consistent diet - you may need sliding scale insulin until your metabolism stabilizes. Followup Instructions: ___
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Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Chief Complaint: Severe Aortic Stenosis Major Surgical or Invasive Procedure: TAVR attempt [MASKED] complicated by hematoma TAVR [MASKED] PPM attempt [MASKED] complicated by RA/RV perforation and cardiac tamponade Mediastinal exploration w/sternotomy [MASKED] External pacing wire and pacer Insertion of permanent pacemaker [MASKED] History of Present Illness: [MASKED] y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, who was admitted on [MASKED] for TAVR. She was previously admitted to the CCU in [MASKED] for AFib with RVR in the setting of an NSTEMI and staph epidermidis bacteremia. An echocardiogram at this time showed moderate/severe aortic stenosis. Cardiac cath revealed normal coronary arteries, moderate/severe aortic stenosis - mean AVG 27 mm Hg, [MASKED] 1.2 cm2, mild elevation of PCW pressure 17 mm Hg and moderate elevation of PA pressure - 59/25. On this admission, the patient endorsed SOB with minimal exertion, intermittent palpitations, and constant [MASKED] edema. She denied syncope, chest pain, and orthopnea. TAVR was attempted on [MASKED], but the procedure was aborted due to Proglide misfiring during PreClose of the right remoral artery, which led to development of a moderate hematoma of the right groin. The hematoma remained soft after 30 minutes hemostasis, and the patient remained hemodynamically stable. She was transferred to the CCU for further management until TAVR could be rescheduled. On arrival to the CCU, patient was intubated with vitals of BP 130/48 HR 49 RR 13 O2 Sat 100% on volume-controlled vent. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF (EF > 55%) - Paroxysmal AFib - NSTEMI [MASKED] 3. OTHER PAST MEDICAL HISTORY Ostomy s/p diverticular resection COPD Hypothyroidism Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ON ADMISSION Vitals: 97.5, 110/71, 69, 94% RA General: Sitting up in bed. No acute distress. Neuro: Alert and oriented x3, speech is clear. MAE. No focal deficits. CV: RRR. + harsh systolic murmur heard at [MASKED] left and right sternal borders radiating to carotids. Pulm: Regular, tachypenic, diminished. Abd: Soft, obesely distended with redundant panus, non-tender to palpation. Ext: Warm and well-perfused. +2 [MASKED] bilat. Mild/mod bilat [MASKED] edema. AT DISCHARGE VS: T 97.9 HR 63 RR 18 BP 102/63 96%2LNC General: sitting up in bed, fatigued Neuro: A&Ox3, NAD, speech clear, no focal deficits. very deconditioned, needs help to sit upright CV: RRR no m/r/g heard Chest: CTAB Abd: obese with redundant panus, colostomy bag in place with stool, patent, +BS, NT Ext: warm and well perfused, +2 [MASKED], mild BLE edema Pertinent Results: ADMISSION LABS: [MASKED] 06:48PM GLUCOSE-93 UREA N-14 CREAT-1.1 SODIUM-142 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18 [MASKED] 06:48PM estGFR-Using this [MASKED] 06:48PM ALT(SGPT)-17 AST(SGOT)-22 CK(CPK)-75 ALK PHOS-80 TOT BILI-0.5 [MASKED]:48PM proBNP-310 [MASKED] 06:48PM ALBUMIN-4.1 [MASKED] 06:48PM TSH-1.7 [MASKED] 06:48PM WBC-8.0 RBC-4.01 HGB-11.7 HCT-36.1 MCV-90 MCH-29.2 MCHC-32.4 RDW-14.7 RDWSD-49.1* [MASKED] 06:48PM PLT COUNT-226 [MASKED] 06:48PM [MASKED] PTT-29.2 [MASKED] TTE [MASKED] Prevalve deployment No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [MASKED] was notified in person of the results on [MASKED] at 1345 Postvalve deployment Evolut valve seen in the aortic position. It appears well seated. There is trival central and perivalvular regurgitation seen. Moderate mitral regurgitation seen. Aorta intact. DISCHARGE LABS: [MASKED] 12:19AM BLOOD Hct-29.1* [MASKED] 12:19AM BLOOD [MASKED] [MASKED] 05:50AM BLOOD Glucose-88 UreaN-26* Creat-1.6* Na-137 K-4.5 Cl-92* HCO3-30 AnGap-15 [MASKED] 05:50AM BLOOD Calcium-7.6* Phos-3.1 Mg-2.0 LFT TREND: [MASKED] 05:50AM BLOOD ALT-134* AST-55* [MASKED] 05:11AM BLOOD ALT-259* AST-53* AlkPhos-152* TotBili-1.8* [MASKED] 05:05AM BLOOD ALT-569* AST-122* LD([MASKED])-337* AlkPhos-191* TotBili-2.1* [MASKED] 04:51AM BLOOD ALT-853* AST-240* LD(LDH)-358* AlkPhos-201* TotBili-2.1* [MASKED] 04:48AM BLOOD ALT-1294* AST-556* AlkPhos-209* TotBili-2.2* [MASKED] 01:29AM BLOOD ALT-2279* AST-1840* LD([MASKED])-625* AlkPhos-224* Amylase-29 TotBili-2.4* [MASKED] 07:44AM BLOOD ALT-2883* AST-3645* AlkPhos-216* Amylase-34 TotBili-2.9* [MASKED] 01:37AM BLOOD ALT-170* AST-462* LD(LDH)-595* AlkPhos-149* TotBili-2.0* [MASKED] 11:14PM BLOOD ALT-34 AST-38 LD(LDH)-338* AlkPhos-74 TotBili-0.7 [MASKED] 06:48PM BLOOD ALT-17 AST-22 CK(CPK)-75 AlkPhos-80 TotBili-0.5 PERMANENT PACEMAKER INFO: Device Generator S/L # Model # Description Manufact Implanted explantDate Status [MASKED] Pacemaker Adapta L [MASKED] ADDRL1 [MASKED] [MASKED] Implanted Leads Loc S/L # Model # Description Manufact Implanted explantDate Status Other [MASKED] Capsure EPI 4968 60cm [MASKED] [MASKED] Prev. Implanted Other [MASKED] Capsure EPI [MASKED] 60cm [MASKED] [MASKED] Prev. Implanted EMR 000 -M 15:40:00 p. [MASKED] Settings Date tested: [MASKED] Generator Mode switch rate Off/NA@ Hysteresis Off/NA Rate Responsive Off/NA Measurements Atrial RV LV SVC/RV Amplitude 5.6mV 11.0mV Pacing impedance 605&#937; 746&#937; Pacing threshold 1.75V 1.75V Threshold pulse width 0.4ms 0.4ms End Procedure Patient status is stable. The distal pulses are unchanged from pre procedure. At the end of the case, the tempoary wire was removed. The patient was transferred to the recovery area. Verbal and written instructions were given to the patient. Verbalizes or communicates understanding of post-procedure instructions. The patient was transported to the holding area in stable condition. Patient transferred to a bed using a slide board. Estimated blood loss during the procedure was 0 mL. No specimen was sent to pathology. Patient status is stable. Skin assessment unchanged from start of case. The distal pulses are unchanged from pre procedure. The IV site is unchanged from the start of the case. The patient was transported to the holding area in stable condition. Patient transferred to a bed using a slide board. All inventory items have been scanned. Radiologic A plane fluoro time 0.6 min B plane fluoro time 0 min Total rads A plane 4 mGy Total rads B plane 0 mGy Conclusion • Successful dual chamber pacemaker generator implant to pre-existing epicardial RA/RV leads. • There were no complications. Brief Hospital Course: [MASKED] y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, who was admitted for TAVR, which was attempted and aborted due to ProGlide misfiring and subsequent hematoma of the right groin. # CORONARIES: no CAD # PUMP: EF >55% # RHYTHM: nsr ACUTE ISSUES # Severe Aortic Stenosis: Patient was admitted for TAVR of her stenosed aortic valve. TAVR was aborted due to complication secondary to difficult vascular access with a hematoma. She underwent TAVR [MASKED], which was complicated by complete heart block, requiring placement of a temporary pacemaker. She was subsequently monitored in the CCU and was hemodynamically stable, extubated [MASKED], and called out to the Cardiology floor on [MASKED]. Pacemaker insertion was attempted on [MASKED] but was complicated by RV perforation (see below) Following recovery from this complication, she was monitored in the ICU and continued diuresis with pericardial drain and transferred out to the regular floor. She continued with diuresis. She declined physical therapy on [MASKED] due to fatigue following her pacemaker but due to her course will require a good deal of therapy to mobilize and increase strength for out of bed activities. Her foley was discontinued on the day of discharge. She will follow up with both Dr. [MASKED] Cardiac [MASKED] for her sternotomy wound as well as her Structural Heart follow up appt. (see DC worksheet) #Complete Heart Block: The patient's TAVR [MASKED] was complicated by complete heart block. She was initially placed on a temporary screw-in pacemaker and monitored in the CCU. EP was consulted and recommended permanent pacemaker placement, which was done [MASKED]. Elective permanent pacemaker placement was attempted on [MASKED], but during positioning of the RV lead, the patient became hypotensive and unresponsive, and was found to have RV perforation. (see below) She ultimately underwent placement of the permanent pacemaker (right sided) on [MASKED] without complication. She will continue oral antibiotics (Clindamycin 450 mg every 8 hours for 5 days, having received her first dose prior to discharge from [MASKED] for surgical prophylaxis following permanent pacemaker insertion. She should take an oral probiotic such as Lactobacillus for 2 weeks, and foods with active cultures such as yogurt and cottage cheese to prevent antibiotic diarrhea. #RV perforation She was found to have a perforation of the RV apex during pacemaker placement attempt on [MASKED]. A pericardial drain was placed for tamponade and initially yielded 420cc of fluid (minimal output since). She sustained cardiac arrest but after 1 min of chest compressions, ROSC was achieved. She was intubated for agonal breathing and transferred to the CCU for further management. The PPM was not placed at this time. On [MASKED], she went for sternotomy, RA/RV repair, and epicardial leads with Cardiac surgery, and was transferred to C-Surg service. The permanent pacemaker was ultimately placed without issues on [MASKED]. She will follow up with Device Clinic in one week for wound check and device interrogation. # Hematoma s/p attempted TAVR for severe aortic stenosis: Patient developed a right groin hematoma following a complication while attempting to attain vascular access for TAVR. She remained hemodynamically stable after hemostasis, and did not require blood transfusion. She was extubated on post-procedure day #1, and ultrasound of the right groin showed no evidence of pseudoaneurysm or AV fistula of the right groin. The procedure was then successfully re-attempted on [MASKED] (see above). #Anemia: The patient's Hgb dropped to 6.7 after TAVR placement. Minimal blood loss was reported during the procedure. She was transfused 2 units of pRBCs, with an appropriate response in Hgb. On [MASKED] she received another 1U PRBC with again appropriate response. She received 2 units [MASKED] and one unit [MASKED] with appropriate response, her Hct on the day of discharge was 29.1. # Paroxysmal AFib: The patient had had multiple previous admissions for AFib with RVR. Her Amiodarone dose was doubled (200 -> 400 mg daily) on discharge from [MASKED] on [MASKED]. From reviewing their notes, it was unclear if the intended discharge dose was 400 daily or 400 BID. She was resumed on amiodarone 400 daily while in the hospital, then ultimately down to 200mg daily after discussing with multiple teams. Her home warfarin 6mg PO daily was held due to her hematoma. She remained in sinus rhythm while in the CCU. The Coumadin was resumed several days later when stable and her INR was 2.1 on the day of discharge. Her Diltiazem was discontinued. Her PCP should resume management of her Coumadin at discharge from rehab. Her Coumadin should be dosed 1 to 5 mg Daily to achieve an INR of 2 to 3.0. CHRONIC ISSUES # Chronic HFpEF Secondary to Severe Aortic Stenosis: There was no evidence of acute volume overload on exam during her inpatient stay. Her home Furosemide 40 mg PO DAILY was held given concern for hypovolemia with hemorrhage after the aborted TAVR procedure. # T2DM: The patient's home MetFORMIN XR (Glucophage XR) 1000 mg PO BID was held, and the patient was kept on Insulin Sliding Scale as an inpatient. The Metformin should continue to be held until her creatinine normalizes to her baseline (1.1 to 1.2) after which her Lantus can be discontinued. We recommend continuing a sliding scale until her metabolism is more stable and her glucose remains stable on before meal and QHS checks. # HLD: The patient's home Atorvastatin 80 mg PO QPM was decreased to 40mg daily due to concern for drug-drug interaction with Amiodarone. # Hypothyroidism: The patient was continued on home Levothyroxine Sodium 50 mcg PO DAILY. # COPD: The patient's home Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob was held, as it was non-formulary. She was placed on an albuterol inhaler Q6hrs while intubated after the aborted TAVR. The patient's home umeclidinium 62.5 mcg/actuation inhalation DAILY was held, as it was also non-formulary. She can resume these at rehab if on formulary. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. umeclidinium 62.5 mcg/actuation inhalation DAILY 2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 3. Diltiazem 30 mg PO TID 4. Amiodarone 400 mg PO BID 5. Warfarin 6 mg PO DAILY16 6. Atorvastatin 80 mg PO QPM 7. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 8. Furosemide 40 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Aspirin EC 81 mg PO DAILY 3. Clindamycin 450 mg PO Q8H Duration: 5 Days Continue for 5 days. First dose given prior to discharge from [MASKED] 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. Lidocaine 5% Patch 2 PTCH TD QPM 12 hrs on, 12 hrs off remove at night 6. Miconazole 2% Cream 1 Appl TP BID to under bilateral breasts 7. Miconazole Powder 2% 1 Appl TP BID:PRN to groin 8. Milk of Magnesia 30 mL PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Amiodarone 200 mg PO DAILY 12. Atorvastatin 40 mg PO QPM 13. Furosemide 80 mg PO DAILY 14. Warfarin [MASKED] mg PO DAILY16 atrial fibrillation for INR goal 2 to 3 Take 5 mg [MASKED], ck. INR [MASKED]. Cyanocobalamin 1000 mcg PO DAILY 16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob 17. Levothyroxine Sodium 50 mcg PO DAILY 18. umeclidinium 62.5 mcg/actuation inhalation DAILY 19. Lactobacillus Twice Daily (or Florastor 100 mg BID) 20. HELD- MetFORMIN XR (Glucophage XR) 1000 mg PO BID This medication was held. Do not restart MetFORMIN XR (Glucophage XR) until Creatinine at baseline 1.1-1.2 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Severe Aortic Stenosis complete heart block hematoma during first TAVR attempt [MASKED] RV perforation during attempted [MASKED] insertion [MASKED] insertion [MASKED] COPD PAF on amiodarone and Coumadin acute on chronic diastolic heart failure acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a procedure to help fix your mitral valve narrowing which was causing shortness of breath and weight gain. We were unable to perform the TAVR procedure on the first try because you started bleeding in your right groin area. We stopped the bleeding and then proceeded with TAVR on [MASKED] with the help of cardiac surgery. You had developed a hematoma during the first attempt of the TAVR and were seen by Vascular Surgery. You developed trouble with the electrical system in the heart after the TAVR and we attempted to place a pacemaker on [MASKED] but had complications due to an RA/RV perforation and acute cardiac tamponade. A drain was placed and you had chest compressions. A temporary pacing wire was placed. You were monitored and cared for closely in the ICU. You continued to be diuresed with Lasix for weight gain and fluid due to your heart failure and underlying cardiac condition. You were transferred to the general floor on [MASKED]. You continued with a temporary pacing wire and external pacemaker until [MASKED] when it was inserted on the right side. There were no complications with the procedure. You will continue with oral antibiotics (Clindamycin 450 mg every 8 hours for 5 days) as prophylaxis to prevent infection at the pacemaker site. Increase intake of foods with probiotics (yogurt, cottage cheeses) and a probiotic such as Lactobacillus for 2 weeks to prevent antibiotic associated diarrhea. Due to your prolonged stay and complications, you have become more deconditioned and had minimal progress with physical therapy due to the pacemaker issues. You should continue to work with out of bed activity, increasing strength, be out of bed for meals and using a commode. Your foley catheter was discontinued on the day of discharge due to risk of infection and you will be due to void 8 hours following discontinuance of the catheter. A urine analysis should be sent at the time of the second void to ensure you do not have a urinary tract infection since the catheter was indwelling for several days. You should be using an incentive spirometer, doing deep breathing and be out of bed regularly to increase strength, endurance and to prevent pneumonia from prolonged bed rest during your recovery. Your Coumadin was stopped prior to the procedures and because of bleeding issues. It was restarted once you were out of the ICU and should be followed by your PCP after discharge from rehab. Your INR goal is 2 to 3. Your INR at discharge was 2.1 on the day of discharge. You will continue with a low dose Aspirin 81 mg Daily to prevent blood clots in your new valve, along with your chronic Coumadin for your AFIB. You should continue to follow a low sodium (2 grams daily) and limit fluids to 1.5 liters daily. You should be weighed daily, preferably on a standing scale for accuracy, with close monitoring of intake and output. If you have increase in weight, your Lasix dose may need to be adjusted. Prior to discharge, you were on 40 mg IV Lasix twice daily, and were changed to 80 mg Daily at discharge. You received 40 mg IV on the morning of discharge and 80 mg PO at the time of discharge. You should resume 80 mg orally in the morning on [MASKED]. Your Amiodarone was decreased to 200 mg a day to help prevent atrial fibrillation. Your Atorvastatin was decreased to 40 mg to minimize reactions from other medications such as Amiodarone. You will follow up in Device Clinic in one week for a wound check and device interrogation for your pacemaker. You will follow up with Structural Heart (appt. information below) and Dr. [MASKED] Cardiac [MASKED] for a wound check. Your Structural Heart appointment will be rescheduled for that same day and your echocardiogram will be done on that day as well. Your rehab should be contacted with this appointment information directly. If they do not receive a call in [MASKED] business days, contact [MASKED] to confirm the date and time. Your Metformin was held due to a rising creatinine and you were placed on a sliding scale insulin and Lantus. When your creatinine returns to normal (1.1 to 1.2) you can resume Metformin and discontinue the Lantus. Your glucose should be monitored and continue a heart healthy carb consistent diet - you may need sliding scale insulin until your metabolism stabilizes. Followup Instructions: [MASKED]
[]
[ "D62", "I480", "N179", "Z7901", "J449", "I110", "E119", "I252", "E669", "E785", "E039", "F17210", "Z794", "K219" ]
[ "I350: Nonrheumatic aortic (valve) stenosis", "R570: Cardiogenic shock", "I314: Cardiac tamponade", "K7200: Acute and subacute hepatic failure without coma", "I5033: Acute on chronic diastolic (congestive) heart failure", "I442: Atrioventricular block, complete", "D62: Acute posthemorrhagic anemia", "I480: Paroxysmal atrial fibrillation", "Z6841: Body mass index [BMI]40.0-44.9, adult", "B368: Other specified superficial mycoses", "N179: Acute kidney failure, unspecified", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure", "L7602: Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating other procedure", "Z538: Procedure and treatment not carried out for other reasons", "Z7901: Long term (current) use of anticoagulants", "J449: Chronic obstructive pulmonary disease, unspecified", "I110: Hypertensive heart disease with heart failure", "E119: Type 2 diabetes mellitus without complications", "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", "I252: Old myocardial infarction", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z933: Colostomy status", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z794: Long term (current) use of insulin", "R0902: Hypoxemia", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,051,074
28,928,117
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, recent TAVR placement ___ complicated by CHB with pacer placement complicated by RV perforation and discharged to rehab on ___ presents with chest pain, dyspnea, N/V that started acutely ___. Her episode of chest pain began the evening of ___, although patient doesn't have clear memory of the exact time or what she was doing. She believes she was lying in bed resting, then had sudden onset, sharp pain with some pressure in epigastrum and radiating to the neck and back. Pain was ___. Had nausea with vomiting x1 and improvement of symptoms. No blood noticed in vomit. The chest pain varies based on her position. Her shortness of breath was better with sitting up than lying down. Patient was admitted ___ for TAVR complicated by complete heart block, pacemaker placement, which was complicated by RV perforation and cardiac tamponade, cardiac arrest with ROSC, and groin hematoma. She had an attempted TAVR on ___, complicated by a groin hematoma, then had TAVR on ___, which was complicated by complete heart block. She had an attempted permanent pacemaker placed on ___, which was complicated by RV perforation and cardiac tamponade, had a drain placed and underwent sternotomy on ___, at which time her RV was repaired and epicardial leads were placed. During her course she also sustained cardiac arrest with ROSC after 1 min of chest compressions. Of note, patient had cath in ___ that showed normal coronary arteries. Also, post-TAVR deployment films ___ showed good flow through RCA and left main arteries at the end of the procedure. Recent device interrogation ___ showed normal pacemaker function. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF (EF > 55%) - Paroxysmal AFib - NSTEMI ___ 3. OTHER PAST MEDICAL HISTORY Ostomy s/p diverticular resection COPD Hypothyroidism Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: T 97.8 PO BP 114/50 R Lying HR 81 RR 18 O2 95 RA GENERAL: Well developed, well nourished obese female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, without drainage. Some scab formation. Diffusely tender to palpation over the chest, pt unclear whether this reproduces pain from previous night. 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, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES: Cool to touch. No clubbing, cyanosis. 1+ pitting edema bilateral lower ext. SKIN: No significant skin lesions or rashes. DISCHARGE SUMMARY ================== VITALS: 98.6 PO 103 / 66 L Sitting 72 18 100 1L GENERAL: morbidly obese, no acute distress, complaining of some diffuse chest pain HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, c/d/i. Some scab formation. Diffusely tender to palpation over the chest. LUNGS: CTABL, no wheezes or crackles ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES:No clubbing, cyanosis, edema SKIN: No significant skin lesions or rashes. Pertinent Results: ADMISSION LABS =================== ___ 05:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-9.2* Hct-30.0* MCV-99* MCH-30.5 MCHC-30.7* RDW-19.1* RDWSD-69.0* Plt ___ ___ 05:50AM BLOOD Neuts-62.1 ___ Monos-13.0 Eos-2.4 Baso-0.2 Im ___ AbsNeut-5.41# AbsLymp-1.82 AbsMono-1.13* AbsEos-0.21 AbsBaso-0.02 ___ 09:15PM BLOOD ___ ___ 05:50AM BLOOD Plt ___ ___ 09:15PM BLOOD Glucose-174* UreaN-21* Creat-1.6* Na-139 K-3.8 HCO3-25 AnGap-14 ___ 05:50AM BLOOD Glucose-119* UreaN-19 Creat-1.6* Na-139 K-4.7 Cl-98 HCO3-24 AnGap-17* ___ 05:50AM BLOOD ALT-22 AST-47* AlkPhos-157* TotBili-0.9 ___ 05:50AM BLOOD Lipase-82* ___ 11:12AM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD proBNP-1340* ___ 09:15PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 ___ 05:50AM BLOOD Albumin-3.4* Calcium-9.0 Phos-4.1 Mg-1.8 ___ 09:15PM BLOOD TSH-3.8 ___ 05:50AM BLOOD HoldBLu-HOLD ___ 09:15PM BLOOD ___ 09:26PM BLOOD Lactate-1.6 ___ 06:00AM BLOOD Lactate-2.3* ECHO ___ ============== The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size is normal with borderline normal free wall function. There is abnormal septal motion suggestive of pericardial constriction (clip 38). The diameters of aorta at the sinus, ascending and arch levels are normal. An Evolut aortic valve bioprosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The effective orifice area/m2 is moderately depressed (0.7; nl >0.9 cm2/m2) No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (clip 48). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. The echo findings are suggestive but not diagnostic of pericardial constriction. A right pleural effusion is present. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No pericardial effusion, but abnormal septal motion suggestive of pericardial constriction. Normal functioning Evolute TAVR with normal gradient and no aortic regurgitation. Compared with the prior study (images reviewed) of ___, the pericardial effusion has resolved and abnormal septal motion is now present suggesting possible pericardial constriction. CXR ___ ============ IMPRESSION: No acute process. Small left pleural effusion. DISCHARGE LABS ================== ___ 05:50AM BLOOD ___ PTT-26.0 ___ ___ 05:50AM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-138 K-3.8 Cl-98 HCO3-26 AnGap-14 ___ 12:00AM BLOOD UreaN-20 Creat-1.5* Na-138 K-4.0 ___ 05:50AM BLOOD ___ PTT-26.0 ___ ___ 12:00AM BLOOD CK(CPK)-35 ___ 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 ___ 12:00AM BLOOD Phos-3.7 Mg-1.8 ___ 05:50AM BLOOD Brief Hospital Course: Ms. ___ is a ___ year old woman with past medical history of aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, COPD, recent TAVR placement ___ complicated by CHB with pacer placement complicated by RV perforation s/p sternotomy with RV repair, discharged to rehab on ___, who presented with chest pain found to most likely be of musculoskeletal etiology. Problems addressed during this hospital admission are as follows: ACTIVE ISSUES: ==================================== #Chest Pain: Sudden onset on ___, sharp, epigastric, radiating to the neck and back, relieved with vomiting x1. On second day of admission, described as dull ache in anterior chest surrounding sternotomy scar. Initially concerning for ACS v dissection v pericarditis v cardiac effusion/restriction v PE v GI (gastroparesis, pancreatitis, GERD). Vital signs stable and workups all negative: EKG nl (LBBB), trops negative, chest x-ray nl, lipase 82, lactate 2.3-->1.6, CBC nl, BMP nl. Blood pressures were equal in both arms. Echo revealed no effusion, some pericardial constriction, most likely related to sternotomy. Most likely musculoskeletal due to relief of pain with oxycodone, reproducible chest tenderness on physical exam. Managed with pain control (oxycodone, Tylenol, lidocaine patch). #Nausea/Vomiting: No episodes of vomiting during admission, tolerated regular diet. Received metoclopramide x1 on admission. #Severe AS s/p TAVR ___ #Complete Heart Block s/p PPM ___ complicated by RV perforation: Last hospitalization (___), patient had TAVR complicated by complete heart block. PPM placed, complicated by RV perforation, cardiac tamponade, cardiac arrest w/ ROSC, s/p sternotomy with RV repair and epicardial lead placement. Repeat echo on this admission revealed good gradients. Continued ASA. #Paroxysmal AFib. Admitted with subtherapeutic INR (___), as warfarin held at rehab due to hematoma, discharge paperwork from pervious admission stated warfarin should have been continued. Restarted home warfarin. CHRONIC/STABLE ISSUES: ==================================== #Heart Failure w/ preserved Ejection Fraction: EF >55% on ___ echo. Thought to be secondary to severe AS. Admission weight: 103.3 kg, discharge weight 103.3 kg. Remained euvolemic, Cr stable. Continued home lasix, spironolactone. #GERD: Switched from ranitidine to omeprazole to better manage GERD. Discharged with ranitidine, continued calcium carbonate. #Normocytic Anemia: Stable, remained at baseline (___). Continued ferrous sulfate. #T2DM: Standing lantus and HISS. #HLD: Continued atorvastatin. #Hypothyroidism. Continued levothyroxine. TRANSITIONAL ISSUES: -Please be sure patient continues to take home warfarin, was discharged on warfarin during last admission (___), however was held at rehab due to a hematoma despite discharge recommendations stating to continue warfarin, admitted with subtherapeutic INR ___ (goal INR ___. -Please check INR on ___, and adjust warfarin dosing as needed. -Can consider switching from ranitidine to PPI for GERD management. #CODE STATUS: Full (presumed) #CONTACT: ___ (husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 20 mEq PO DAILY 2. Epoetin ___ ___ units SC QWEEK 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 40 mg PO BID 5. Spironolactone 25 mg PO BID 6. Calcium Carbonate 1000 mg PO QID:PRN GERD 7. umeclidinium 62.5 mcg/actuation inhalation DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 12. Milk of Magnesia 30 mL PO DAILY constipation 13. Amiodarone 200 mg PO DAILY 14. Cyanocobalamin 100 mcg PO DAILY 15. Ranitidine 150 mg PO DAILY 16. Miconazole 2% Cream 1 Appl TP BID rash 17. Miconazole Powder 2% 1 Appl TP BID rash 18. Levothyroxine Sodium 50 mcg PO DAILY 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 20. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 21. GuaiFENesin 10 mL PO Q4H:PRN cough 22. Bisacodyl 10 mg PR QHS:PRN constipation 23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 24. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin Discharge Medications: 1. Nicotine Patch 14 mg TD DAILY 2. Warfarin 6 mg PO DAILY16 3. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 6. Amiodarone 200 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Bisacodyl 10 mg PR QHS:PRN constipation 10. Calcium Carbonate 1000 mg PO QID:PRN GERD 11. Cyanocobalamin 100 mcg PO DAILY 12. Epoetin ___ ___ units SC QWEEK 13. Ferrous Sulfate 325 mg PO BID 14. Furosemide 40 mg PO BID 15. GuaiFENesin 10 mL PO Q4H:PRN cough 16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 17. Levothyroxine Sodium 50 mcg PO DAILY 18. Lidocaine 5% Patch 1 PTCH TD QAM 19. Miconazole 2% Cream 1 Appl TP BID rash 20. Miconazole Powder 2% 1 Appl TP BID rash 21. Milk of Magnesia 30 mL PO DAILY constipation 22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*9 Tablet Refills:*0 23. Potassium Chloride 20 mEq PO DAILY Hold for K > 24. Ranitidine 150 mg PO DAILY 25. Spironolactone 25 mg PO BID 26. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Chest Pain SECONDARY DIAGNOSES ===================== aortic stenosis s/p TAVR Paroxysmal Atrial fibrillation chronic diastolic heart failure GERD HLD T2DM COPD Diverticulitis s/p partial colectomy Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. You came to the hospital because you had chest pain. We performed blood tests, EKGs, which measure the electrical activity of the heart, and a heart ultrasound to evaluate your chest pain. The results of the tests we performed were all normal. We believe the chest pain is related to the joints and muscles surrounding your heart, especially because you recently had a surgical procedure in your chest. Your symptoms improved with pain medications which you will be able to take after you leave the hospital. Please be sure to follow up with your doctors as listed below and to take all of your prescribed medications. We wish you all the best! -Your ___ care team Followup Instructions: ___
[ "R0789", "I252", "Z8674", "I110", "I5032", "E119", "E538", "D649", "Z954", "I480", "Z7901", "Z933", "Z720", "J449", "Z794", "Z950", "E785", "E039", "K219", "K5900", "R21", "N6459", "E6601", "Z6839" ]
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, recent TAVR placement [MASKED] complicated by CHB with pacer placement complicated by RV perforation and discharged to rehab on [MASKED] presents with chest pain, dyspnea, N/V that started acutely [MASKED]. Her episode of chest pain began the evening of [MASKED], although patient doesn't have clear memory of the exact time or what she was doing. She believes she was lying in bed resting, then had sudden onset, sharp pain with some pressure in epigastrum and radiating to the neck and back. Pain was [MASKED]. Had nausea with vomiting x1 and improvement of symptoms. No blood noticed in vomit. The chest pain varies based on her position. Her shortness of breath was better with sitting up than lying down. Patient was admitted [MASKED] for TAVR complicated by complete heart block, pacemaker placement, which was complicated by RV perforation and cardiac tamponade, cardiac arrest with ROSC, and groin hematoma. She had an attempted TAVR on [MASKED], complicated by a groin hematoma, then had TAVR on [MASKED], which was complicated by complete heart block. She had an attempted permanent pacemaker placed on [MASKED], which was complicated by RV perforation and cardiac tamponade, had a drain placed and underwent sternotomy on [MASKED], at which time her RV was repaired and epicardial leads were placed. During her course she also sustained cardiac arrest with ROSC after 1 min of chest compressions. Of note, patient had cath in [MASKED] that showed normal coronary arteries. Also, post-TAVR deployment films [MASKED] showed good flow through RCA and left main arteries at the end of the procedure. Recent device interrogation [MASKED] showed normal pacemaker function. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF (EF > 55%) - Paroxysmal AFib - NSTEMI [MASKED] 3. OTHER PAST MEDICAL HISTORY Ostomy s/p diverticular resection COPD Hypothyroidism Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: T 97.8 PO BP 114/50 R Lying HR 81 RR 18 O2 95 RA GENERAL: Well developed, well nourished obese female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, without drainage. Some scab formation. Diffusely tender to palpation over the chest, pt unclear whether this reproduces pain from previous night. 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, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES: Cool to touch. No clubbing, cyanosis. 1+ pitting edema bilateral lower ext. SKIN: No significant skin lesions or rashes. DISCHARGE SUMMARY ================== VITALS: 98.6 PO 103 / 66 L Sitting 72 18 100 1L GENERAL: morbidly obese, no acute distress, complaining of some diffuse chest pain HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, c/d/i. Some scab formation. Diffusely tender to palpation over the chest. LUNGS: CTABL, no wheezes or crackles ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES:No clubbing, cyanosis, edema SKIN: No significant skin lesions or rashes. Pertinent Results: ADMISSION LABS =================== [MASKED] 05:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-9.2* Hct-30.0* MCV-99* MCH-30.5 MCHC-30.7* RDW-19.1* RDWSD-69.0* Plt [MASKED] [MASKED] 05:50AM BLOOD Neuts-62.1 [MASKED] Monos-13.0 Eos-2.4 Baso-0.2 Im [MASKED] AbsNeut-5.41# AbsLymp-1.82 AbsMono-1.13* AbsEos-0.21 AbsBaso-0.02 [MASKED] 09:15PM BLOOD [MASKED] [MASKED] 05:50AM BLOOD Plt [MASKED] [MASKED] 09:15PM BLOOD Glucose-174* UreaN-21* Creat-1.6* Na-139 K-3.8 HCO3-25 AnGap-14 [MASKED] 05:50AM BLOOD Glucose-119* UreaN-19 Creat-1.6* Na-139 K-4.7 Cl-98 HCO3-24 AnGap-17* [MASKED] 05:50AM BLOOD ALT-22 AST-47* AlkPhos-157* TotBili-0.9 [MASKED] 05:50AM BLOOD Lipase-82* [MASKED] 11:12AM BLOOD cTropnT-<0.01 [MASKED] 05:50AM BLOOD cTropnT-<0.01 [MASKED] 05:50AM BLOOD proBNP-1340* [MASKED] 09:15PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 [MASKED] 05:50AM BLOOD Albumin-3.4* Calcium-9.0 Phos-4.1 Mg-1.8 [MASKED] 09:15PM BLOOD TSH-3.8 [MASKED] 05:50AM BLOOD HoldBLu-HOLD [MASKED] 09:15PM BLOOD [MASKED] 09:26PM BLOOD Lactate-1.6 [MASKED] 06:00AM BLOOD Lactate-2.3* ECHO [MASKED] ============== The left atrium is mildly dilated. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size is normal with borderline normal free wall function. There is abnormal septal motion suggestive of pericardial constriction (clip 38). The diameters of aorta at the sinus, ascending and arch levels are normal. An Evolut aortic valve bioprosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The effective orifice area/m2 is moderately depressed (0.7; nl >0.9 cm2/m2) No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (clip 48). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. The echo findings are suggestive but not diagnostic of pericardial constriction. A right pleural effusion is present. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No pericardial effusion, but abnormal septal motion suggestive of pericardial constriction. Normal functioning Evolute TAVR with normal gradient and no aortic regurgitation. Compared with the prior study (images reviewed) of [MASKED], the pericardial effusion has resolved and abnormal septal motion is now present suggesting possible pericardial constriction. CXR [MASKED] ============ IMPRESSION: No acute process. Small left pleural effusion. DISCHARGE LABS ================== [MASKED] 05:50AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 05:50AM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-138 K-3.8 Cl-98 HCO3-26 AnGap-14 [MASKED] 12:00AM BLOOD UreaN-20 Creat-1.5* Na-138 K-4.0 [MASKED] 05:50AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 12:00AM BLOOD CK(CPK)-35 [MASKED] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 05:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 [MASKED] 12:00AM BLOOD Phos-3.7 Mg-1.8 [MASKED] 05:50AM BLOOD Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with past medical history of aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, COPD, recent TAVR placement [MASKED] complicated by CHB with pacer placement complicated by RV perforation s/p sternotomy with RV repair, discharged to rehab on [MASKED], who presented with chest pain found to most likely be of musculoskeletal etiology. Problems addressed during this hospital admission are as follows: ACTIVE ISSUES: ==================================== #Chest Pain: Sudden onset on [MASKED], sharp, epigastric, radiating to the neck and back, relieved with vomiting x1. On second day of admission, described as dull ache in anterior chest surrounding sternotomy scar. Initially concerning for ACS v dissection v pericarditis v cardiac effusion/restriction v PE v GI (gastroparesis, pancreatitis, GERD). Vital signs stable and workups all negative: EKG nl (LBBB), trops negative, chest x-ray nl, lipase 82, lactate 2.3-->1.6, CBC nl, BMP nl. Blood pressures were equal in both arms. Echo revealed no effusion, some pericardial constriction, most likely related to sternotomy. Most likely musculoskeletal due to relief of pain with oxycodone, reproducible chest tenderness on physical exam. Managed with pain control (oxycodone, Tylenol, lidocaine patch). #Nausea/Vomiting: No episodes of vomiting during admission, tolerated regular diet. Received metoclopramide x1 on admission. #Severe AS s/p TAVR [MASKED] #Complete Heart Block s/p PPM [MASKED] complicated by RV perforation: Last hospitalization ([MASKED]), patient had TAVR complicated by complete heart block. PPM placed, complicated by RV perforation, cardiac tamponade, cardiac arrest w/ ROSC, s/p sternotomy with RV repair and epicardial lead placement. Repeat echo on this admission revealed good gradients. Continued ASA. #Paroxysmal AFib. Admitted with subtherapeutic INR ([MASKED]), as warfarin held at rehab due to hematoma, discharge paperwork from pervious admission stated warfarin should have been continued. Restarted home warfarin. CHRONIC/STABLE ISSUES: ==================================== #Heart Failure w/ preserved Ejection Fraction: EF >55% on [MASKED] echo. Thought to be secondary to severe AS. Admission weight: 103.3 kg, discharge weight 103.3 kg. Remained euvolemic, Cr stable. Continued home lasix, spironolactone. #GERD: Switched from ranitidine to omeprazole to better manage GERD. Discharged with ranitidine, continued calcium carbonate. #Normocytic Anemia: Stable, remained at baseline ([MASKED]). Continued ferrous sulfate. #T2DM: Standing lantus and HISS. #HLD: Continued atorvastatin. #Hypothyroidism. Continued levothyroxine. TRANSITIONAL ISSUES: -Please be sure patient continues to take home warfarin, was discharged on warfarin during last admission ([MASKED]), however was held at rehab due to a hematoma despite discharge recommendations stating to continue warfarin, admitted with subtherapeutic INR [MASKED] (goal INR [MASKED]. -Please check INR on [MASKED], and adjust warfarin dosing as needed. -Can consider switching from ranitidine to PPI for GERD management. #CODE STATUS: Full (presumed) #CONTACT: [MASKED] (husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 20 mEq PO DAILY 2. Epoetin [MASKED] [MASKED] units SC QWEEK 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 40 mg PO BID 5. Spironolactone 25 mg PO BID 6. Calcium Carbonate 1000 mg PO QID:PRN GERD 7. umeclidinium 62.5 mcg/actuation inhalation DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 12. Milk of Magnesia 30 mL PO DAILY constipation 13. Amiodarone 200 mg PO DAILY 14. Cyanocobalamin 100 mcg PO DAILY 15. Ranitidine 150 mg PO DAILY 16. Miconazole 2% Cream 1 Appl TP BID rash 17. Miconazole Powder 2% 1 Appl TP BID rash 18. Levothyroxine Sodium 50 mcg PO DAILY 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 20. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 21. GuaiFENesin 10 mL PO Q4H:PRN cough 22. Bisacodyl 10 mg PR QHS:PRN constipation 23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 24. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin Discharge Medications: 1. Nicotine Patch 14 mg TD DAILY 2. Warfarin 6 mg PO DAILY16 3. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 6. Amiodarone 200 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Bisacodyl 10 mg PR QHS:PRN constipation 10. Calcium Carbonate 1000 mg PO QID:PRN GERD 11. Cyanocobalamin 100 mcg PO DAILY 12. Epoetin [MASKED] [MASKED] units SC QWEEK 13. Ferrous Sulfate 325 mg PO BID 14. Furosemide 40 mg PO BID 15. GuaiFENesin 10 mL PO Q4H:PRN cough 16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 17. Levothyroxine Sodium 50 mcg PO DAILY 18. Lidocaine 5% Patch 1 PTCH TD QAM 19. Miconazole 2% Cream 1 Appl TP BID rash 20. Miconazole Powder 2% 1 Appl TP BID rash 21. Milk of Magnesia 30 mL PO DAILY constipation 22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*9 Tablet Refills:*0 23. Potassium Chloride 20 mEq PO DAILY Hold for K > 24. Ranitidine 150 mg PO DAILY 25. Spironolactone 25 mg PO BID 26. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Chest Pain SECONDARY DIAGNOSES ===================== aortic stenosis s/p TAVR Paroxysmal Atrial fibrillation chronic diastolic heart failure GERD HLD T2DM COPD Diverticulitis s/p partial colectomy Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to care for you at the [MASKED] [MASKED]. You came to the hospital because you had chest pain. We performed blood tests, EKGs, which measure the electrical activity of the heart, and a heart ultrasound to evaluate your chest pain. The results of the tests we performed were all normal. We believe the chest pain is related to the joints and muscles surrounding your heart, especially because you recently had a surgical procedure in your chest. Your symptoms improved with pain medications which you will be able to take after you leave the hospital. Please be sure to follow up with your doctors as listed below and to take all of your prescribed medications. We wish you all the best! -Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "I252", "I110", "I5032", "E119", "D649", "I480", "Z7901", "J449", "Z794", "E785", "E039", "K219", "K5900" ]
[ "R0789: Other chest pain", "I252: Old myocardial infarction", "Z8674: Personal history of sudden cardiac arrest", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "E538: Deficiency of other specified B group vitamins", "D649: Anemia, unspecified", "Z954: Presence of other heart-valve replacement", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z933: Colostomy status", "Z720: Tobacco use", "J449: Chronic obstructive pulmonary disease, unspecified", "Z794: Long term (current) use of insulin", "Z950: Presence of cardiac pacemaker", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "K5900: Constipation, unspecified", "R21: Rash and other nonspecific skin eruption", "N6459: Other signs and symptoms in breast", "E6601: Morbid (severe) obesity due to excess calories", "Z6839: Body mass index [BMI] 39.0-39.9, adult" ]
10,051,352
23,908,367
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chronic cholecystitis Major Surgical or Invasive Procedure: ___: Laparoscopic cholecystectomy History of Present Illness: The patient is a ___ with RUQ pain for the past 5 hours that woke him from sleep. He had similar pain last night as well after eating a cheeseburger, which improved on its own. Today, the pain is constant and not improving. He endorses nausea, but no vomiting. No fevers at home. His bowels have been overall normal, but he thinks a little more constipated than usual due to decreased water intake. No bloody stools. He tried taking prune juice when his pain started this morning, which made his pain worse. He did have one prior episode of abdominal pain similar to this when he was seen in the ED last year, and was sent home with a bowel regimen. Past Medical History: non-contributory Social History: ___ Family History: Non contributory Physical Exam: Prior to Discharge: VS: 98.3, 71, 112/65, 18, 100% RA GEN: Pleasant with NAD HEENT: No scleral icterus CV: RRR, no M/R/G PULM: CTAB ABD: laparoscopic incisions open to air and c/d/I EXTR: Warm, no c/c/e Pertinent Results: ___ 04:15AM BLOOD WBC-9.3 RBC-3.91* Hgb-13.0* Hct-38.5* MCV-99* MCH-33.2* MCHC-33.8 RDW-11.9 RDWSD-42.9 Plt ___ ___ 04:15AM BLOOD Glucose-141* UreaN-16 Creat-1.3* Na-133 K-5.2* Cl-99 HCO3-23 AnGap-16 ___ 04:15AM BLOOD ALT-154* AST-229* AlkPhos-73 TotBili-0.7 ___ GALLBLADDER US: IMPRESSION: Cholelithiasis without evidence of gallbladder wall thickening or gallbladder distention. Negative sonographic ___ signs. Of note, there is a 1.2 cm stone in the gallbladder neck. Brief Hospital Course: The patient was admitted to the Acute Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal ultra-sound revealed gallstone disease. The patient underwent laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquid, on IV fluids, and Oxycodone for pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge on POD 1, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 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. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chronic cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at ___ with acute cholecystitis. You underwent cholecystectomy. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Acute Care Surgery at ___ if you have any questions or concerns. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: ___
[ "K8000", "K828" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chronic cholecystitis Major Surgical or Invasive Procedure: [MASKED]: Laparoscopic cholecystectomy History of Present Illness: The patient is a [MASKED] with RUQ pain for the past 5 hours that woke him from sleep. He had similar pain last night as well after eating a cheeseburger, which improved on its own. Today, the pain is constant and not improving. He endorses nausea, but no vomiting. No fevers at home. His bowels have been overall normal, but he thinks a little more constipated than usual due to decreased water intake. No bloody stools. He tried taking prune juice when his pain started this morning, which made his pain worse. He did have one prior episode of abdominal pain similar to this when he was seen in the ED last year, and was sent home with a bowel regimen. Past Medical History: non-contributory Social History: [MASKED] Family History: Non contributory Physical Exam: Prior to Discharge: VS: 98.3, 71, 112/65, 18, 100% RA GEN: Pleasant with NAD HEENT: No scleral icterus CV: RRR, no M/R/G PULM: CTAB ABD: laparoscopic incisions open to air and c/d/I EXTR: Warm, no c/c/e Pertinent Results: [MASKED] 04:15AM BLOOD WBC-9.3 RBC-3.91* Hgb-13.0* Hct-38.5* MCV-99* MCH-33.2* MCHC-33.8 RDW-11.9 RDWSD-42.9 Plt [MASKED] [MASKED] 04:15AM BLOOD Glucose-141* UreaN-16 Creat-1.3* Na-133 K-5.2* Cl-99 HCO3-23 AnGap-16 [MASKED] 04:15AM BLOOD ALT-154* AST-229* AlkPhos-73 TotBili-0.7 [MASKED] GALLBLADDER US: IMPRESSION: Cholelithiasis without evidence of gallbladder wall thickening or gallbladder distention. Negative sonographic [MASKED] signs. Of note, there is a 1.2 cm stone in the gallbladder neck. Brief Hospital Course: The patient was admitted to the Acute Surgical Service on [MASKED] for evaluation and treatment of abdominal pain. Admission abdominal ultra-sound revealed gallstone disease. The patient underwent laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquid, on IV fluids, and Oxycodone for pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge on POD 1, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 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. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chronic cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [MASKED] with acute cholecystitis. You underwent cholecystectomy. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Acute Care Surgery at [MASKED] if you have any questions or concerns. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: [MASKED]
[]
[]
[ "K8000: Calculus of gallbladder with acute cholecystitis without obstruction", "K828: Other specified diseases of gallbladder" ]
10,051,500
26,049,591
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Sore Throat Major Surgical or Invasive Procedure: ___ EGD History of Present Illness: ___ with PMhx of HTN presents with chest pain and sore throat. Per patient, she notes that 2d PTA, she developed a foreign body sensation in her throat. She notes that since development, it is always there, and is associated with dysphagia and odynophagia. She denies issues with secretions, vomiting, nausea, hematemesis, abdominal pain, diarrhea, melena, BRBPR. She denies foreign body ingestion. She notes that she went to an outpatient GI appointment, where she was expecting definitive treatment, and elected to present to the ED as no endoscopy was planned for that day. It was recommended that she undergo GI consultation for possible esophageal spasm. She denies a history of progressive dysphagia to solids or liquids. In the ED, initial vitals: 98.1 73 148/86 18 99% RA Labs were significant for - normal CBC, Chem7, BUN/Cr ___ (near Atrius baseline ___ - negative trop x 1 Imaging showed - CXR: poor inspiratory effort, ?cardiomegaly, cephalization of vasculature, ___, right hilar fullness, no effusions or focal infiltrates (my read) In the ED, she received no medications. Exam remarkable for ttp over sternum. Past Medical History: HTN IFGT HLD Obesity Depression Positive PPD Social History: ___ Family History: Daughter required esophageal dilation for ?stricture in mid-___ Physical Exam: ADMISSION ========= VS: 98.3 132/79 66 18 95% RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: CTAB without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema DISCHARGE ========= Vitals: 98.3 135/76 60 18 96% ra GEN: WDWN female in NAD HEENT: anicteric, MOM, symmetric palatal elevation, no retropharyngeal edema, exudate NECK: supple, JVP not elevated, no LAD, masses, fluctuance LUNGS: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1S2, no M/R/G ABD: obese, soft, NT/ND, NABS GU: no foley EXT: WWP, 2+ pulses, no cyanosis or edema NEURO: A&Ox3, face symmetric, MAE SKIN: warm and dry Pertinent Results: ADMISSION LABS ============== ___ 06:00PM WBC-9.2 RBC-5.04 HGB-14.5 HCT-44.4 MCV-88 MCH-28.8 MCHC-32.7 RDW-14.1 RDWSD-45.2 ___ 06:00PM NEUTS-49.8 ___ MONOS-6.4 EOS-1.8 BASOS-0.7 IM ___ AbsNeut-4.59 AbsLymp-3.79* AbsMono-0.59 AbsEos-0.17 AbsBaso-0.06 ___ 06:00PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14 ___ 06:00PM cTropnT-<0.01 PERTINENT STUDIES ================= ___ 06:08AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 12:30PM URINE Color-Straw Appear-Clear Sp ___ ___:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ======= CHEST (PA & LAT) Study Date of ___ 2:47 ___ No radiopaque foreign body seen projecting over the course of the esophagus. ___ EGD Impression: Erythema, friability and congestion with exudates in the lower third of the esophagus and middle third of the esophagus compatible with esophagitis (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - Will contact you with biopsy results - Start PO Omeprazole 40 mg Q12H for now - Diet as tolerated DISCHARGE LABS ============== ___ 06:15AM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-141 K-3.9 Cl-105 HCO3-23 AnGap-17 ___ 06:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.___ female with history of HTN, HLD, IFGT and obesity who presented with 2 days of odynophagia to solids and liquids without evidence of airway compromise, autoimmune symptoms, anemia or abscess. She underwent upper endoscopy which was notable for esophagitis without evidence of bleeding. Mucosal biopsies pending at time of discharge. Patient responded to IV PPI BID and continued to improve on oral PPI BID. She was tolerating regular diet and was discharged on omeprazole 40mg BID with PCP follow up. # Odynophagia Presented with 2 days of throat pain, subjective throat swelling, and inability to swallow. Initially there was concern for cardiac etiology given sub-sternal nature of the pain, but EKG unremarkable for ischemia and troponin was negative x 2. No foreign body identified on CXR, no pneumomediastinum or subcutaneous emphysema. Treated with diltiazem for concern for diffuse esophageal spasm but patient did not respond to this therapy. Patient underwent EGD ___ that showed erythema and exudates in mid and distal esophagus which likely represents esophagitis from reflux. She was started on IV PPI BID with good response to anti-reflux therapy. She was tolerating regular diet and was discharged on omeprazole 40mg BID with PCP follow up. ___ biopsies pending at time of discharge. CHRONIC ISSUES # HTN: home medications initially held given normotension and poor oral intake. BP rose after endoscopy and with resumption of oral nutrition. Restarted home lisinopril 10mg QD, triamterene-HCTZ (37.5/25) QD. # HLD: home statin initially held given interaction between pravastatin and diltiazem for possible esophageal spasm. Diltiazem was discontinued and restarted home simvastatin 20mg QD # Allergic rhinitis: stable. Continued home fluticasone and held home cetirizine-pseudoephedrine. # Code: Full, confirmed # Communication: ___ (son) ___ TRANSITIONAL ISSUES =================== [ ] started on BID omeprazole 40mg [ ] mucosal biopsies pending at discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. cetirizine-pseudoephedrine ___ mg oral Q12H 6. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Omeprazole 40 mg PO Q12H RX *omeprazole 40 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*60 Capsule Refills:*0 2. cetirizine-pseudoephedrine ___ mg oral Q12H 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 5. Lisinopril 10 mg PO DAILY 6. Simvastatin 20 mg PO QPM 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Reflux esophagitis 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 ___ on ___ with painful swallowing. You had an endoscopy that showed damage from acid reflux. You were started on a twice daily acid blocking medication and your symptoms improved. You were able to eat and drink prior to leaving the hospital. Please continue to take the acid blocker omeprazole, twice a day. Follow up with your primary care physician. If you develop throat swelling, drooling, voice changes, shortness of breath or have bloody vomiting, please contact your physician immediately or return to the hospital. We wish you the best in health. Sincerely, Your ___ Team Followup Instructions: ___
[ "K210", "E7800", "I10", "E669", "Z6830", "J309" ]
Allergies: Penicillins Chief Complaint: Sore Throat Major Surgical or Invasive Procedure: [MASKED] EGD History of Present Illness: [MASKED] with PMhx of HTN presents with chest pain and sore throat. Per patient, she notes that 2d PTA, she developed a foreign body sensation in her throat. She notes that since development, it is always there, and is associated with dysphagia and odynophagia. She denies issues with secretions, vomiting, nausea, hematemesis, abdominal pain, diarrhea, melena, BRBPR. She denies foreign body ingestion. She notes that she went to an outpatient GI appointment, where she was expecting definitive treatment, and elected to present to the ED as no endoscopy was planned for that day. It was recommended that she undergo GI consultation for possible esophageal spasm. She denies a history of progressive dysphagia to solids or liquids. In the ED, initial vitals: 98.1 73 148/86 18 99% RA Labs were significant for - normal CBC, Chem7, BUN/Cr [MASKED] (near Atrius baseline [MASKED] - negative trop x 1 Imaging showed - CXR: poor inspiratory effort, ?cardiomegaly, cephalization of vasculature, [MASKED], right hilar fullness, no effusions or focal infiltrates (my read) In the ED, she received no medications. Exam remarkable for ttp over sternum. Past Medical History: HTN IFGT HLD Obesity Depression Positive PPD Social History: [MASKED] Family History: Daughter required esophageal dilation for ?stricture in mid-[MASKED] Physical Exam: ADMISSION ========= VS: 98.3 132/79 66 18 95% RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: CTAB without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema DISCHARGE ========= Vitals: 98.3 135/76 60 18 96% ra GEN: WDWN female in NAD HEENT: anicteric, MOM, symmetric palatal elevation, no retropharyngeal edema, exudate NECK: supple, JVP not elevated, no LAD, masses, fluctuance LUNGS: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1S2, no M/R/G ABD: obese, soft, NT/ND, NABS GU: no foley EXT: WWP, 2+ pulses, no cyanosis or edema NEURO: A&Ox3, face symmetric, MAE SKIN: warm and dry Pertinent Results: ADMISSION LABS ============== [MASKED] 06:00PM WBC-9.2 RBC-5.04 HGB-14.5 HCT-44.4 MCV-88 MCH-28.8 MCHC-32.7 RDW-14.1 RDWSD-45.2 [MASKED] 06:00PM NEUTS-49.8 [MASKED] MONOS-6.4 EOS-1.8 BASOS-0.7 IM [MASKED] AbsNeut-4.59 AbsLymp-3.79* AbsMono-0.59 AbsEos-0.17 AbsBaso-0.06 [MASKED] 06:00PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14 [MASKED] 06:00PM cTropnT-<0.01 PERTINENT STUDIES ================= [MASKED] 06:08AM BLOOD CK-MB-3 cTropnT-<0.01 [MASKED] 12:30PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED]:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ======= CHEST (PA & LAT) Study Date of [MASKED] 2:47 [MASKED] No radiopaque foreign body seen projecting over the course of the esophagus. [MASKED] EGD Impression: Erythema, friability and congestion with exudates in the lower third of the esophagus and middle third of the esophagus compatible with esophagitis (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - Will contact you with biopsy results - Start PO Omeprazole 40 mg Q12H for now - Diet as tolerated DISCHARGE LABS ============== [MASKED] 06:15AM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-141 K-3.9 Cl-105 HCO3-23 AnGap-17 [MASKED] 06:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.[MASKED] female with history of HTN, HLD, IFGT and obesity who presented with 2 days of odynophagia to solids and liquids without evidence of airway compromise, autoimmune symptoms, anemia or abscess. She underwent upper endoscopy which was notable for esophagitis without evidence of bleeding. Mucosal biopsies pending at time of discharge. Patient responded to IV PPI BID and continued to improve on oral PPI BID. She was tolerating regular diet and was discharged on omeprazole 40mg BID with PCP follow up. # Odynophagia Presented with 2 days of throat pain, subjective throat swelling, and inability to swallow. Initially there was concern for cardiac etiology given sub-sternal nature of the pain, but EKG unremarkable for ischemia and troponin was negative x 2. No foreign body identified on CXR, no pneumomediastinum or subcutaneous emphysema. Treated with diltiazem for concern for diffuse esophageal spasm but patient did not respond to this therapy. Patient underwent EGD [MASKED] that showed erythema and exudates in mid and distal esophagus which likely represents esophagitis from reflux. She was started on IV PPI BID with good response to anti-reflux therapy. She was tolerating regular diet and was discharged on omeprazole 40mg BID with PCP follow up. [MASKED] biopsies pending at time of discharge. CHRONIC ISSUES # HTN: home medications initially held given normotension and poor oral intake. BP rose after endoscopy and with resumption of oral nutrition. Restarted home lisinopril 10mg QD, triamterene-HCTZ (37.5/25) QD. # HLD: home statin initially held given interaction between pravastatin and diltiazem for possible esophageal spasm. Diltiazem was discontinued and restarted home simvastatin 20mg QD # Allergic rhinitis: stable. Continued home fluticasone and held home cetirizine-pseudoephedrine. # Code: Full, confirmed # Communication: [MASKED] (son) [MASKED] TRANSITIONAL ISSUES =================== [ ] started on BID omeprazole 40mg [ ] mucosal biopsies pending at discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. cetirizine-pseudoephedrine [MASKED] mg oral Q12H 6. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Omeprazole 40 mg PO Q12H RX *omeprazole 40 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*60 Capsule Refills:*0 2. cetirizine-pseudoephedrine [MASKED] mg oral Q12H 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 5. Lisinopril 10 mg PO DAILY 6. Simvastatin 20 mg PO QPM 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Reflux esophagitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] on [MASKED] with painful swallowing. You had an endoscopy that showed damage from acid reflux. You were started on a twice daily acid blocking medication and your symptoms improved. You were able to eat and drink prior to leaving the hospital. Please continue to take the acid blocker omeprazole, twice a day. Follow up with your primary care physician. If you develop throat swelling, drooling, voice changes, shortness of breath or have bloody vomiting, please contact your physician immediately or return to the hospital. We wish you the best in health. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10", "E669" ]
[ "K210: Gastro-esophageal reflux disease with esophagitis", "E7800: Pure hypercholesterolemia, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "J309: Allergic rhinitis, unspecified" ]
10,051,658
27,577,432
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: back and leg pain Major Surgical or Invasive Procedure: ___ LUMBAR MICRODISCECTOMY, LEFT L5-S1 History of Present Illness: Mr. ___ is a ___ male who in ___ developed sudden onset of back pain and leg pain. He says his back hurts. It is difficult for him to stand up straight and he is leaning over to one side. He had eight weeks of physical therapy, three epidural steroid injections and is using medication and ice. He works as a ___ and as a ___, but has not been working since the incident. He reports some paresthesias and pain in his left leg following an S1 distribution and intermittent decreased strength. He was most recently seen by the Pain Clinic. They offered him repeat epidural steroid injections, but he only had minimal relief. He does not want to take pain medication over the counter and also physical therapy has not helped him. The patient was seen in clinic to see if there are any more options for him. An MRI from ___ is available for review. It shows foraminal narrowing at C3-C4 and L4-L5 and moderate lumbar stenosis severe and effacement of the left S1 nerve root from a massive disc herniation at L5-S1. Past Medical History: Lumbar stenosis L5-S1 disc herniation Social History: ___ Family History: NC Physical Exam: On discharge: Alert and oriented x3. Face symmetrical. Tongue midline. No pronator drift. Moves all extremities full strength ___. Numbness in the left lower extremity from posterior lateral thigh to L ___ toe. Incision is well approximated with surgical glue. Brief Hospital Course: Mr. ___ underwent an elective left L5-S1 microdiscectomy on ___ without complications. He was extubated and recovered in the PACU. He complained of L lateral leg numbness from his posterior thigh to the outer L foot. He was transferred to the floor and remained neurologically stable. His pain was well controlled and he was ambulating without difficulty. On discharge his incision is well approximated without redness, drainage, or swelling. He was discharged to home with follow-up in the ___ clinic. Medications on Admission: Ibuprofen Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain Do not exceed 4GM acetaminophen in 24 hours 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: L5-S1 left paracentral disc herniation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Spine Surgery without Fusion Surgery •Your incision is closed with dissolvable sutures underneath the skin. You do not need suture removal. Please keep your incision dry for 72 hours after surgery. •Do not apply any lotions or creams to the site. •Please avoid swimming for two weeks. •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. Followup Instructions: ___
[ "M5117" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: back and leg pain Major Surgical or Invasive Procedure: [MASKED] LUMBAR MICRODISCECTOMY, LEFT L5-S1 History of Present Illness: Mr. [MASKED] is a [MASKED] male who in [MASKED] developed sudden onset of back pain and leg pain. He says his back hurts. It is difficult for him to stand up straight and he is leaning over to one side. He had eight weeks of physical therapy, three epidural steroid injections and is using medication and ice. He works as a [MASKED] and as a [MASKED], but has not been working since the incident. He reports some paresthesias and pain in his left leg following an S1 distribution and intermittent decreased strength. He was most recently seen by the Pain Clinic. They offered him repeat epidural steroid injections, but he only had minimal relief. He does not want to take pain medication over the counter and also physical therapy has not helped him. The patient was seen in clinic to see if there are any more options for him. An MRI from [MASKED] is available for review. It shows foraminal narrowing at C3-C4 and L4-L5 and moderate lumbar stenosis severe and effacement of the left S1 nerve root from a massive disc herniation at L5-S1. Past Medical History: Lumbar stenosis L5-S1 disc herniation Social History: [MASKED] Family History: NC Physical Exam: On discharge: Alert and oriented x3. Face symmetrical. Tongue midline. No pronator drift. Moves all extremities full strength [MASKED]. Numbness in the left lower extremity from posterior lateral thigh to L [MASKED] toe. Incision is well approximated with surgical glue. Brief Hospital Course: Mr. [MASKED] underwent an elective left L5-S1 microdiscectomy on [MASKED] without complications. He was extubated and recovered in the PACU. He complained of L lateral leg numbness from his posterior thigh to the outer L foot. He was transferred to the floor and remained neurologically stable. His pain was well controlled and he was ambulating without difficulty. On discharge his incision is well approximated without redness, drainage, or swelling. He was discharged to home with follow-up in the [MASKED] clinic. Medications on Admission: Ibuprofen Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain Do not exceed 4GM acetaminophen in 24 hours 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: L5-S1 left paracentral disc herniation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Spine Surgery without Fusion Surgery •Your incision is closed with dissolvable sutures underneath the skin. You do not need suture removal. Please keep your incision dry for 72 hours after surgery. •Do not apply any lotions or creams to the site. •Please avoid swimming for two weeks. •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. Followup Instructions: [MASKED]
[]
[]
[ "M5117: Intervertebral disc disorders with radiculopathy, lumbosacral region" ]
10,051,850
21,845,745
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right hip pain/fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ pleasant Femail with pmhx of anemia, schizophrenia, dementia, who was transferred from an outside hospital for a fall with R hip pain. Unable to elicit history ___ patient mental status. CT head/C-spine negative. Past Medical History: None on File Social History: ___ Family History: None on File Physical Exam: AVSS NAD RLE No open wounds observed to move legs, wiggles toes/moves feet; limited by pain Sensation exam deferred ___ mental status wwp distally. Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have Right hip fracture and was admitted to the orthopedic surgery service. After long discussion with the surgical team, family, palliative care team, nursing staff, and hospice care team. The decision was made to forego surgery at this point and pursue hospice care for comfort. If any questions or concerns arise regarding the hip fracture, may contact Dr. ___ in the ___ Trauma Clinic ___ to schedule appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Tartrate 25 mg PO BID 9. Atorvastatin 40 mg PO QPM 10. TraZODone 12.5 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Apply to affected area q72 Hrs Disp #*100 Patch Refills:*0 5. Glycopyrrolate 0.1-0.2 mg IV Q6H:PRN Dry Mouth 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN Pain - Mild RX *morphine concentrate 20 mg/mL 4 mg by mouth ___ q1H Disp #*100 Syringe Refills:*0 8. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN Agitation 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: R hip fracture (previous hardware in femoral shaft) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC INPATIENT ADMISSION: - You were in the hospital after fracturing your hip. It is normal to feel tired or "washed out" after this injury. ACTIVITY AND WEIGHT BEARING: per patient comfort MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue medications prescribed under palliative care/hospice team - 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. Physical Therapy: NWB - Activity per patient comfort Treatment Frequency: Per Hospice service Followup Instructions: ___
[ "S72141A", "F0390", "F200", "Z66", "E039", "I10", "D509", "W19XXXA", "Y92129", "Z515" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right hip pain/fracture Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] pleasant Femail with pmhx of anemia, schizophrenia, dementia, who was transferred from an outside hospital for a fall with R hip pain. Unable to elicit history [MASKED] patient mental status. CT head/C-spine negative. Past Medical History: None on File Social History: [MASKED] Family History: None on File Physical Exam: AVSS NAD RLE No open wounds observed to move legs, wiggles toes/moves feet; limited by pain Sensation exam deferred [MASKED] mental status wwp distally. Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have Right hip fracture and was admitted to the orthopedic surgery service. After long discussion with the surgical team, family, palliative care team, nursing staff, and hospice care team. The decision was made to forego surgery at this point and pursue hospice care for comfort. If any questions or concerns arise regarding the hip fracture, may contact Dr. [MASKED] in the [MASKED] Trauma Clinic [MASKED] to schedule appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Tartrate 25 mg PO BID 9. Atorvastatin 40 mg PO QPM 10. TraZODone 12.5 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Apply to affected area q72 Hrs Disp #*100 Patch Refills:*0 5. Glycopyrrolate 0.1-0.2 mg IV Q6H:PRN Dry Mouth 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL [MASKED] mg PO Q1H:PRN Pain - Mild RX *morphine concentrate 20 mg/mL 4 mg by mouth [MASKED] q1H Disp #*100 Syringe Refills:*0 8. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN Agitation 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: R hip fracture (previous hardware in femoral shaft) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC INPATIENT ADMISSION: - You were in the hospital after fracturing your hip. It is normal to feel tired or "washed out" after this injury. ACTIVITY AND WEIGHT BEARING: per patient comfort MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue medications prescribed under palliative care/hospice team - 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. Physical Therapy: NWB - Activity per patient comfort Treatment Frequency: Per Hospice service Followup Instructions: [MASKED]
[]
[ "Z66", "E039", "I10", "D509", "Z515" ]
[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "F0390: Unspecified dementia without behavioral disturbance", "F200: Paranoid schizophrenia", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "D509: Iron deficiency anemia, unspecified", "W19XXXA: Unspecified fall, initial encounter", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause", "Z515: Encounter for palliative care" ]
10,051,872
21,380,555
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of T1D on Humalog insulin pump (followed by Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. He reports that his blood sugar has been under good control today (low 200s) until this morning when he noted it to be 220 prior to breakfast. He then went out to eat and when he returned noted his glucose to be in the 500s. He set his pump to deliver additional insulin boluses and reports that he received approximately 1500 units between 3pm and 9pm when he presented to the ___. He typically receives a basal infusion plus boluses of ___ for meals. He reports 3 episodes of NBNB vomiting, no fevers, chills, abdominal pain, diarrhea, dysuria, or cough. No known sick contacts. He was initially diagnosed with T1D in ___ and received an insulin pump ___ years ago. His BG was initially very difficult to control and he reports three prior episodes of DKA, last being in ___ at which time he was thought to have a pump malfunction and it was replaced. At ___, he was found to have a BG in the 500s, Bicarb 11, and anion gap 29 c/w DKA, with WBC of 17. CXR concerning for a possible pneumonia and he was initiated on vanc/zosyn. He was started on an insulin drip, given 2 L of fluids and transferred here since no ICU beds available at ___. The patient felt well on arrival to our ___. Denied any pain and breathing comfortably. Clear lungs and normal heart sounds. Soft and non-tender abdomen. Mild tachycardia (90s-100s) with stable BPs 120-130s/40-50s, SaO2 94-96% RA. He was continued on an insulin drip. ___ L NS administered. Additional ___ L with K running at 250 per hour. Antibiotics continued with Vanc and Zosyn. Labs: WBC 17 -> 20.5, Bicarb 11 -> 8, Glucose 519 -> 425 -> 372, Anion gap 29 - > 25, K 4.7. ROS: Positives as per HPI; otherwise negative. Past Medical History: T1DM Hypothyroid Hypertension Prior CVA Social History: ___ Family History: Not obtained Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: HR 78, BP 134/59, O2 99% RA, BG 465 GEN: Well appearing HEENT: No JVD CV: RRR RESP: CTAB GI: Soft, non-tender, non-distended MSK: No abnormalities SKIN: WWP NEURO: Mentating appropriately, neurologic exam grossly intact DISCHARGE PHYSICAL EXAM: ======================= 24 HR Data (last updated ___ @ 807) Temp: 97.6 (Tm 98.7), BP: 161/88 (139-181/63-92), HR: 64 (55-68), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA GEN: Alert, NAD, appears comfortable CV: RRR; no m/r/g PULM: breathing comfortably, clear to auscultation bilaterally, no wheezes, ronchi or crackles NEURO: AAOx3, grossly intact, moving all 4 extremities spontaneously and with purpose Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 01:20AM BLOOD WBC-20.5* RBC-4.74 Hgb-14.7 Hct-46.4 MCV-98 MCH-31.0 MCHC-31.7* RDW-13.8 RDWSD-49.8* Plt ___ ___ 05:01AM BLOOD ___ PTT-26.5 ___ ___ 01:20AM BLOOD Glucose-425* UreaN-30* Creat-1.4* Na-144 K-4.7 Cl-111* HCO3-8* AnGap-25* ___ 01:20AM BLOOD Phos-4.4 Mg-2.0 ___ 03:25AM BLOOD Beta-OH-4.1* ___ 01:26AM BLOOD Glucose-419* Lactate-2.9* Na-138 K-4.1 Cl-115* calHCO3-9* ___ 03:25AM BLOOD ___ pO2-48* pCO2-20* pH-7.22* calTCO2-9* Base XS--17 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== =========================== REPORTS AND IMAGING STUDIES =========================== ___ IMPRESSION: Low lung volumes. No good evidence for cardiopulmonary abnormality. Although no acute or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma, or other osseous soft tissue abnormality involving the chest wall is clinically warranted, the location of any referable focal findings should be described in the imaging request, clearly marked, and imaged with either bone detail radiographs or Chest CT scanning. ============ MICROBIOLOGY ============ ___ Blood Culture #1 = ___ Blood Culture #2 = ============================ DISCHARGE LABS ============================== ___ 04:43AM BLOOD WBC-9.6 RBC-4.72 Hgb-14.5 Hct-43.0 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.4 RDWSD-45.1 Plt ___ ___ 04:43AM BLOOD Plt ___ ___ 04:43AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-144 K-4.0 Cl-108 HCO3-26 AnGap-10 ___ 04:43AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old man with a history of T1D on Humalog insulin pump (followed by Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. #Diabetic Ketoacidosis Mr. ___ presented in DKA with anion gap of 25, serum glucose of 425, elevated beta hydroxybuterate and a metabolic acidosis. He was initiated on an insulin infusion, normal saline boluses, and potassium and phosphate repletion. His gap rapidly closed and his beta hydroxy-buterate trended to zero. His acidosis also rapidly resolved. His insulin infusion was eventually weaned down per protocol and when it reached 4u/hour we initiated insulin subcutaneously with a initial basal dose of 28u glargine, standing humalog of 3u per meal and a sliding scale. He was able to eat at this time and he was then transferred to the floor. The etiology of his DKA was not immediately clear. He reports multiple prior episodes. CXR did not reveal pneumonia and a UA at an OSH did not show evidence of infection. His leukocytosis was thought to be reactive. There was concern that his insulin pump may have malfunctioned, though there was no clear evidence this was the case. ___ endocrinology was consulted. FLOOR COURSE: # DKA now resolved: # Type I DM Patient was continued on SC insulin at the time of transfer to the floor. Due to some issue with his insulin order, the patient did not receive his QHS glargine on the evening of ___. Subsequently had high BG readings the next AM w/ sugars in the 400s. He received 28u of lantus and IVF w/ improvement in his sugars. He had his insulin adjusted by ___ and ___ be discharged with a regimen of #######. He will follow up with his endocrinologist, Dr. ___. #Hx recent CVA #Mild aphasia: Patient and his wife were concerned about him exhibiting word-finding difficulties (cardinal symptom noted during stroke a couple weeks ago) and some fine motor difficulties (he was unable to write in his usual cursive and instead tried to write in print, unable to draw his wife a picture and per her is usually a great artist) at the time of his admission to the MICU. This was thought to be most likely recrudescence in the setting of his DKA as it improved w/ treatment of that condition. Patient notably with a recent CVA (2 weeks ago) during which ___ neuro noted reported "L subcortical location and distribution of the stroke is most consistent with a small vessel occlusive mechanism." Carotid U/S noting "Bilateral carotid bulb and proximal ICA soft atherosclerotic plaque, left >right." Carotid disease thought to be possibly the culprit though no residual disease which would be amenable to surgical intervention. TTE fairly unremarkable and w/o e/o intracardiac thrombi. Sent home w/ holter monitor (no results communicated to patient yet). He reports history of intermittent "fast heart rate" but is not sure if it is a-fib and no documented history of this. Per ___ notes appears to be some unspecified SVT, w/ AVNRT noted on tele on the AM of ___. He was monitored for the rest of the admission and with no concern for new deficits which might suggest a CVA. He will be referred to neuro at the time of discharge. #SVT #Likely AVNRT: Patient w/ self-limited episodes of SVT which appeared to be AVNRT on the AM of ___. He was hemodynamically stable and asymptomatic. He reports having palpitations in the past and having "fast heart rates" followed by Dr. ___. Notably not on any nodal blockade as an outpatient. He was started on a low dose of metoprolol, but was limited by bradycardia so he was not discharged on this. # Hypertension: SBP in the 200s overnight on ___ but reassuringly asymptomatic. He continued to have elevated BPs during this admission and so had his antihypertensive regimen titrated. He was on a regimen including an increased dose of lisinopril at the time of discharge. # Leukocytosis: Admitted w/ a WBC of 20K. Thought to be reactive in the setting of DKA. WBC downtrended over the course of the admission, and the patient had no localizing signs/symptoms of infection. CHRONIC ISSUES =============== # Hyperlipidemia: Continued home atorvastatin # Hypothyroid: Continued home levothyroxine TRANSITIONAL ISSUES: ================== []Patient discharged on basal/bolus insulin regimen. He should follow up with his endocrinologist, Dr. ___. []Discharged on Lisinopril 40 for hypertension. Follow up BP for titration of his antihypertensives []Patient referred to neuro for follow up after his recent CVA Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. tadalafil 2.5 mg oral DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Glargine 28 Units Bedtime Humalog 7 Units Breakfast Humalog 7 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*1 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 5 Units QID per sliding scale 7 Units before LNCH; Units QID per sliding scale 7 Units before DINR; Units QID per sliding scale Disp #*1 Syringe Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY nasal congestion 3. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. tadalafil 2.5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: DKA SVT Hypertensive urgency 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 confused and feeling unwell at home and were found to be in a dangerous condition called diabetic ketoacidosis. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were admitted to the ICU where you were given insulin, fluid, and electrolytes. Your condition improved quite quickly. - You were evaluated by the doctors from ___. Your insulin regimen was adjusted, and you will go out on injectable insulin instead of your insulin pump. - You had elevated blood pressures and had your blood pressure medications increased. 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: ___
[ "E1010", "I471", "R4701", "N179", "Z9641", "I6523", "Z8673", "I10", "D72829", "E785", "E039", "I160", "Z006", "E1065" ]
Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of T1D on Humalog insulin pump (followed by Dr. [MASKED] at [MASKED], HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. He reports that his blood sugar has been under good control today (low 200s) until this morning when he noted it to be 220 prior to breakfast. He then went out to eat and when he returned noted his glucose to be in the 500s. He set his pump to deliver additional insulin boluses and reports that he received approximately 1500 units between 3pm and 9pm when he presented to the [MASKED]. He typically receives a basal infusion plus boluses of [MASKED] for meals. He reports 3 episodes of NBNB vomiting, no fevers, chills, abdominal pain, diarrhea, dysuria, or cough. No known sick contacts. He was initially diagnosed with T1D in [MASKED] and received an insulin pump [MASKED] years ago. His BG was initially very difficult to control and he reports three prior episodes of DKA, last being in [MASKED] at which time he was thought to have a pump malfunction and it was replaced. At [MASKED], he was found to have a BG in the 500s, Bicarb 11, and anion gap 29 c/w DKA, with WBC of 17. CXR concerning for a possible pneumonia and he was initiated on vanc/zosyn. He was started on an insulin drip, given 2 L of fluids and transferred here since no ICU beds available at [MASKED]. The patient felt well on arrival to our [MASKED]. Denied any pain and breathing comfortably. Clear lungs and normal heart sounds. Soft and non-tender abdomen. Mild tachycardia (90s-100s) with stable BPs 120-130s/40-50s, SaO2 94-96% RA. He was continued on an insulin drip. [MASKED] L NS administered. Additional [MASKED] L with K running at 250 per hour. Antibiotics continued with Vanc and Zosyn. Labs: WBC 17 -> 20.5, Bicarb 11 -> 8, Glucose 519 -> 425 -> 372, Anion gap 29 - > 25, K 4.7. ROS: Positives as per HPI; otherwise negative. Past Medical History: T1DM Hypothyroid Hypertension Prior CVA Social History: [MASKED] Family History: Not obtained Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: HR 78, BP 134/59, O2 99% RA, BG 465 GEN: Well appearing HEENT: No JVD CV: RRR RESP: CTAB GI: Soft, non-tender, non-distended MSK: No abnormalities SKIN: WWP NEURO: Mentating appropriately, neurologic exam grossly intact DISCHARGE PHYSICAL EXAM: ======================= 24 HR Data (last updated [MASKED] @ 807) Temp: 97.6 (Tm 98.7), BP: 161/88 (139-181/63-92), HR: 64 (55-68), RR: 18 ([MASKED]), O2 sat: 94% (94-98), O2 delivery: RA GEN: Alert, NAD, appears comfortable CV: RRR; no m/r/g PULM: breathing comfortably, clear to auscultation bilaterally, no wheezes, ronchi or crackles NEURO: AAOx3, grossly intact, moving all 4 extremities spontaneously and with purpose Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ [MASKED] 01:20AM BLOOD WBC-20.5* RBC-4.74 Hgb-14.7 Hct-46.4 MCV-98 MCH-31.0 MCHC-31.7* RDW-13.8 RDWSD-49.8* Plt [MASKED] [MASKED] 05:01AM BLOOD [MASKED] PTT-26.5 [MASKED] [MASKED] 01:20AM BLOOD Glucose-425* UreaN-30* Creat-1.4* Na-144 K-4.7 Cl-111* HCO3-8* AnGap-25* [MASKED] 01:20AM BLOOD Phos-4.4 Mg-2.0 [MASKED] 03:25AM BLOOD Beta-OH-4.1* [MASKED] 01:26AM BLOOD Glucose-419* Lactate-2.9* Na-138 K-4.1 Cl-115* calHCO3-9* [MASKED] 03:25AM BLOOD [MASKED] pO2-48* pCO2-20* pH-7.22* calTCO2-9* Base XS--17 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== =========================== REPORTS AND IMAGING STUDIES =========================== [MASKED] IMPRESSION: Low lung volumes. No good evidence for cardiopulmonary abnormality. Although no acute or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma, or other osseous soft tissue abnormality involving the chest wall is clinically warranted, the location of any referable focal findings should be described in the imaging request, clearly marked, and imaged with either bone detail radiographs or Chest CT scanning. ============ MICROBIOLOGY ============ [MASKED] Blood Culture #1 = [MASKED] Blood Culture #2 = ============================ DISCHARGE LABS ============================== [MASKED] 04:43AM BLOOD WBC-9.6 RBC-4.72 Hgb-14.5 Hct-43.0 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.4 RDWSD-45.1 Plt [MASKED] [MASKED] 04:43AM BLOOD Plt [MASKED] [MASKED] 04:43AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-144 K-4.0 Cl-108 HCO3-26 AnGap-10 [MASKED] 04:43AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with a history of T1D on Humalog insulin pump (followed by Dr. [MASKED] at [MASKED], HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. #Diabetic Ketoacidosis Mr. [MASKED] presented in DKA with anion gap of 25, serum glucose of 425, elevated beta hydroxybuterate and a metabolic acidosis. He was initiated on an insulin infusion, normal saline boluses, and potassium and phosphate repletion. His gap rapidly closed and his beta hydroxy-buterate trended to zero. His acidosis also rapidly resolved. His insulin infusion was eventually weaned down per protocol and when it reached 4u/hour we initiated insulin subcutaneously with a initial basal dose of 28u glargine, standing humalog of 3u per meal and a sliding scale. He was able to eat at this time and he was then transferred to the floor. The etiology of his DKA was not immediately clear. He reports multiple prior episodes. CXR did not reveal pneumonia and a UA at an OSH did not show evidence of infection. His leukocytosis was thought to be reactive. There was concern that his insulin pump may have malfunctioned, though there was no clear evidence this was the case. [MASKED] endocrinology was consulted. FLOOR COURSE: # DKA now resolved: # Type I DM Patient was continued on SC insulin at the time of transfer to the floor. Due to some issue with his insulin order, the patient did not receive his QHS glargine on the evening of [MASKED]. Subsequently had high BG readings the next AM w/ sugars in the 400s. He received 28u of lantus and IVF w/ improvement in his sugars. He had his insulin adjusted by [MASKED] and [MASKED] be discharged with a regimen of #######. He will follow up with his endocrinologist, Dr. [MASKED]. #Hx recent CVA #Mild aphasia: Patient and his wife were concerned about him exhibiting word-finding difficulties (cardinal symptom noted during stroke a couple weeks ago) and some fine motor difficulties (he was unable to write in his usual cursive and instead tried to write in print, unable to draw his wife a picture and per her is usually a great artist) at the time of his admission to the MICU. This was thought to be most likely recrudescence in the setting of his DKA as it improved w/ treatment of that condition. Patient notably with a recent CVA (2 weeks ago) during which [MASKED] neuro noted reported "L subcortical location and distribution of the stroke is most consistent with a small vessel occlusive mechanism." Carotid U/S noting "Bilateral carotid bulb and proximal ICA soft atherosclerotic plaque, left >right." Carotid disease thought to be possibly the culprit though no residual disease which would be amenable to surgical intervention. TTE fairly unremarkable and w/o e/o intracardiac thrombi. Sent home w/ holter monitor (no results communicated to patient yet). He reports history of intermittent "fast heart rate" but is not sure if it is a-fib and no documented history of this. Per [MASKED] notes appears to be some unspecified SVT, w/ AVNRT noted on tele on the AM of [MASKED]. He was monitored for the rest of the admission and with no concern for new deficits which might suggest a CVA. He will be referred to neuro at the time of discharge. #SVT #Likely AVNRT: Patient w/ self-limited episodes of SVT which appeared to be AVNRT on the AM of [MASKED]. He was hemodynamically stable and asymptomatic. He reports having palpitations in the past and having "fast heart rates" followed by Dr. [MASKED]. Notably not on any nodal blockade as an outpatient. He was started on a low dose of metoprolol, but was limited by bradycardia so he was not discharged on this. # Hypertension: SBP in the 200s overnight on [MASKED] but reassuringly asymptomatic. He continued to have elevated BPs during this admission and so had his antihypertensive regimen titrated. He was on a regimen including an increased dose of lisinopril at the time of discharge. # Leukocytosis: Admitted w/ a WBC of 20K. Thought to be reactive in the setting of DKA. WBC downtrended over the course of the admission, and the patient had no localizing signs/symptoms of infection. CHRONIC ISSUES =============== # Hyperlipidemia: Continued home atorvastatin # Hypothyroid: Continued home levothyroxine TRANSITIONAL ISSUES: ================== []Patient discharged on basal/bolus insulin regimen. He should follow up with his endocrinologist, Dr. [MASKED]. []Discharged on Lisinopril 40 for hypertension. Follow up BP for titration of his antihypertensives []Patient referred to neuro for follow up after his recent CVA Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. tadalafil 2.5 mg oral DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Glargine 28 Units Bedtime Humalog 7 Units Breakfast Humalog 7 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*1 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 5 Units QID per sliding scale 7 Units before LNCH; Units QID per sliding scale 7 Units before DINR; Units QID per sliding scale Disp #*1 Syringe Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY nasal congestion 3. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. tadalafil 2.5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: DKA SVT Hypertensive urgency 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 confused and feeling unwell at home and were found to be in a dangerous condition called diabetic ketoacidosis. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were admitted to the ICU where you were given insulin, fluid, and electrolytes. Your condition improved quite quickly. - You were evaluated by the doctors from [MASKED]. Your insulin regimen was adjusted, and you will go out on injectable insulin instead of your insulin pump. - You had elevated blood pressures and had your blood pressure medications increased. 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]
[]
[ "N179", "Z8673", "I10", "E785", "E039" ]
[ "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "I471: Supraventricular tachycardia", "R4701: Aphasia", "N179: Acute kidney failure, unspecified", "Z9641: Presence of insulin pump (external) (internal)", "I6523: Occlusion and stenosis of bilateral carotid arteries", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "D72829: Elevated white blood cell count, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "I160: Hypertensive urgency", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E1065: Type 1 diabetes mellitus with hyperglycemia" ]
10,051,990
24,801,170
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fevers, abdominal Pain Major Surgical or Invasive Procedure: Paracentesis ___ History of Present Illness: ___ y/o male with a history alcoholism c/b DT, siezure disorder, TBI s/p SAH after a fall, alcoholic cirrhosis c/b known varices s/p banding in ___ and diabetes presents with fever and abdominal pain to OSH from jail. At ___ he had a: RUQ US - gallbladder thickening c/w liver disease, no stones, no obstruction, +cirrhosis CT a/p - cirrhosis with small amount of ascites, diffuse stranding; GB wall edema could be secondary to cirrhosis and third-spacing, no definitive stones, could do HIDA for definitive r/o cholecystitis; diffuse colonic wall edema, more stranding around ascending colon, could represent colitis patient received zosyn, on third liter of IVF borderline blood pressures in 90's, tachcyardic to 110's Started on peripheral levophed He was transferred to ___ because of cirrhosis history. In the ___, initial vitals: 7 ___ 96% RA Was started on protonix, octreotide, vancomycin. He was evaluated by GI- will follow no need for emergent scope given stable hemodynamics ACS- who requested he be seen by transplant Transplant - who will continue to follow but recommends EGD and ___ Rectal was positive for blood. neg melena. Of note he was admitted to ___ in ___ with BRBPR and left before being scoped because he had a court date. He was also recently admitted to ___ in ___ with bilateral PNA, metabolic encephalopathy. On transfer, vitals were:2 99.4 110 100/52 18 97% RA On arrival to the MICU, patient was accompanied by security gaurds. He states that he started having abdominal pain ___ sharp in the RUQ extending up and down the flank shortly after lunch. Constant in nature not made better or worse with movement. Associated with lightheadedness when he stands up. Denies f/c/cp/sob/n/v/orthopnea/leg swelling. This became worse after dinner which sent him into the hospital. Reports scant blood on TP after normal brown stools, no melena. Past Medical History: hemochromatosis HTN HLD anxiety Lyme Hepatitis alcoholic insomnia seizure pulmonary nodule diabetes type two Social History: ___ Family History: Mother had diabetes-now deceased. Father is deceased. No family history of liver disease or cancer. Physical Exam: ========================== ADMISSION PHYSICAL ========================== Vitals: T:98.4 BP:118/67 P:80 R:22 O2:97% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: obese with spider angioma in the epigastrum TTP over the diffusely localizing over the RUQ, hepatomegaly no splenomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash, no jaundice NEURO: CN ___ intact, no asterixis, ___ strength bilaterally ACCESS: Left femoral ========================== DISCHARGE PHYSICAL ========================== Vital Signs: 98.1 98 / 46 85 16 95ra General: Alert, orientedx3 HEENT: Sclera anicteric, EOMI Lungs: CTA bilaterally CV: rrr, holosystolic murmur II/VI Abdomen: murphys sign not present, bowel sounds present, mild discomfort upon palpation of RUQ, improved since yesterday Ext: Warm, well perfused Pertinent Results: ========================== ADMISSION LABS ========================== ___ 02:00AM BLOOD WBC-8.1 RBC-3.45* Hgb-9.8* Hct-30.6* MCV-89 MCH-28.4 MCHC-32.0 RDW-17.8* RDWSD-58.2* Plt Ct-68* ___ 06:41AM BLOOD WBC-16.5*# RBC-3.45* Hgb-9.8* Hct-31.3* MCV-91 MCH-28.4 MCHC-31.3* RDW-17.7* RDWSD-58.6* Plt Ct-66* ___ 02:00AM BLOOD Neuts-77* Bands-10* Lymphs-1* Monos-10 Eos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-7.05* AbsLymp-0.08* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.00* ___ 06:41AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND Baso-PND AbsNeut-PND AbsLymp-PND AbsMono-PND AbsEos-PND AbsBaso-PND ___ 02:00AM BLOOD ___ PTT-36.7* ___ ___ 02:00AM BLOOD Plt Smr-VERY LOW Plt Ct-68* ___ 06:41AM BLOOD ___ PTT-37.1* ___ ___ 06:41AM BLOOD Plt Ct-66* ___ 02:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ ___ 02:00AM BLOOD Glucose-71 UreaN-11 Creat-0.9 Na-139 K-3.1* Cl-107 HCO3-18* AnGap-17 ___ 02:00AM BLOOD ALT-28 AST-46* AlkPhos-106 TotBili-3.0* DirBili-PND ___ 02:00AM BLOOD cTropnT-<0.01 ___ 02:00AM BLOOD Lipase-55 ___ 02:00AM BLOOD Albumin-2.7* Calcium-8.0* Phos-2.4* Mg-1.3* ___ 05:07AM BLOOD ___ pO2-49* pCO2-31* pH-7.38 calTCO2-19* Base XS--5 ___ 06:54AM BLOOD Type-CENTRAL VE Temp-36.7 pO2-49* pCO2-31* pH-7.38 calTCO2-19* Base XS--5 Intubat-NOT INTUBA ___ 02:25AM BLOOD Lactate-3.5* ___ 05:07AM BLOOD Lactate-4.5* ___ 06:54AM BLOOD Lactate-4.3* K-3.4 ___ 06:54AM BLOOD freeCa-1.05* ___ 05:07AM BLOOD O2 Sat-81 ========================== DISCHARGE LABS ========================== ___ 08:12AM BLOOD WBC-2.8* RBC-3.60* Hgb-9.9* Hct-32.1* MCV-89 MCH-27.5 MCHC-30.8* RDW-18.3* RDWSD-59.0* Plt Ct-82* ___ 07:46AM BLOOD Neuts-59.3 ___ Monos-13.3* Eos-1.3 Baso-0.4 Im ___ AbsNeut-1.38* AbsLymp-0.59* AbsMono-0.31 AbsEos-0.03* AbsBaso-0.01 ___ 08:12AM BLOOD ___ PTT-40.7* ___ ___ 08:12AM BLOOD Glucose-74 UreaN-9 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-22 AnGap-15 ___ 08:12AM BLOOD ALT-14 AST-31 AlkPhos-79 TotBili-2.5* ___ 08:12AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.7 ========================== OTHER IMPORTANT LABS ========================== ___ 01:24PM ASCITES WBC-86* RBC-475* Polys-24* Lymphs-38* ___ Mesothe-5* Macroph-33* ___ 01:24PM ASCITES TotPro-1.1 Glucose-124 LD(LDH)-45 Albumin-0.6 ___ 08:03AM BLOOD calTIBC-181* Ferritn-64 TRF-139* ___ 08:03AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative HAV Ab-Positive ___ 08:03AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 08:03AM BLOOD ___ ___ 08:03AM BLOOD HIV Ab-Negative ___ 02:00AM BLOOD Lipase-55 ___ 02:00AM BLOOD cTropnT-<0.01 ========================== IMAGING ========================== ___ CT A/P IMPRESSION: 1. Diffuse colonic wall edema could be secondary to portal hypertensive colopathy. However, there is relative increased fat stranding around the ascending colon and cecum as well as hyperemia that is concerning for possible colitis particularly given the patient's symptoms on the right. 2. Cirrhotic liver with sequela of portal hypertension including recanalization of the umbilical vein common extensive varices (including gastric and esophageal), splenomegaly, and small volume ascites. Overall heterogeneous enhancement is likely related to cirrhosis, but cannot exclude focal lesions. If concern, nonurgent dedicated hepatic imaging could be considered. 3. Extensive gallbladder wall edema is likely the sequela of chronic liver disease given the absence significant gallbladder distention.However, this could be further evaluated with a HIDA scan, if clinically indicated. 4. Diverticulosis without evidence of diverticulitis. ___ RUQ U/S IMPRESSION: 1. Cirrhotic liver with evidence of portal hypertension including a recanalized umbilical vein and small volume ascites. 2. Extensive gallbladder wall edema is likely related to chronic hepatic disease given the absence of significant gallbladder wall distension and cholelithiasis. If clinical concern, however, HIDA scan could be considered for further evaluation. ___ CTA A/P IMPRESSION: 1. No evidence of mesenteric ischemia. 2. Cirrhotic-appearing liver with sequelae of portal hypertension including ascites, splenomegaly, colopathy, recanalization of the paraumbilical vein, and numerous collaterals as well as gastric varices. 3. Nonspecific diffuse colonic edema with surrounding fat stranding, likely from portal hypertensive colopathy, but concurrent colitis from infection or inflammation is probable. 4. No evidence of active hemorrhage on this exam. 5. Mild sigmoid diverticulosis. 6. Gallbladder edema is likely from third spacing and reactive in setting of liver disease with ascites. ___ HIDA SCAN IMPRESSION: Abnormal hepatobiliary scan with delayed appearance of tracer into the gallbladder. At 4 hours minimal tracer is noted in the gallbladder fossa. Findings most consistent with chronic cholecystitis; however, the minimal tracer uptake in the gallbladder fossa at 4 hours and the appearance of edema on CT makes it difficult to entirely rule out acute cholecystitis. ___ ABDOMINAL FLAT/UPRIGHT IMPRESSION: 1. Diffuse mild gaseous distention of the small bowel loops without abnormal dilation of small bowel nor large bowel suggests ileus. 2. Mild thickening of the wall of the transverse colon is consistent with known history of colitis. 3. No free intraperitoneal air seen on left lateral decubitus view. ___ CXR IMPRESSION: No acute cardiopulmonary process or evidence pneumonia. Probable small pleural effusions bilaterally. ___ RUQ ULTRASOUND IMPRESSION: 1. Cirrhosis with evidence of portal hypertension including splenomegaly, small to moderate volume ascites, and a recanalized umbilical vein. 2. Gallbladder wall edema is likely related to chronic hepatic disease given relative gallbladder ___. 3. Cholelithiasis. ========================== MICRO ========================== ___ Blood cultures no growth x ___ Urine culture no growth ___ stool cultures C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. ___ 1:24 pm PERITONEAL FLUID GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: BRIEF SUMMARY: ============== ___, incarcerated with PMH of Alcohol Abuse (complicated by DTs/Seizure, sober since ___, seizure disorder, h/o TBI, hemochromatosis, EtOH/HCV cirrhosis (c/b varices, banded in ___, T2DM who presented initially to OSH with acute onset of fever and abdominal pain. Imaging showing mostly complications of portal hypertension but given acute onset of fevers, pain, lactate elevation, and bilirubin elevation was consistent with cholecystistis, confirmed on HIDA scan. Transplant surgery and internventional radiology were consulted who deemed patient too high risk to undergo invasive intervention. Cholecystitis was managed with antibiotics with adequate response. Patient was also seen hepatology who recommended outpatient establishment with hepatologist to continue care for his cirrhosis. ACUTE ISSUES: ============= # Acute cholecystitis: In the MICU, warm on exam with evidence of abdominal infection on CT and elevated total bilirubin concerning for cholangitis/cholecystitis. He was treated with albumin infusions and pressor support with levophed, while being started on Ciprofloxacin and Flagyl. Upon arrival from MICU, patient noted to have obvious rebound tenderness of exam. A flat and upright was negative for free air, HIDA scan showed minimal tracer uptake into the gallbladder at 4 hours. When placed in context with acute onset of fevers and abdominal pain and leukocytosis, we presumed a diagnosis of acute cholecystitis. Transplant surgery was consulted, who stated Mr. ___ was too high risk for cholecystectomy. Interventional radiology was consulted, who stated the gallbladder was not particularly distended, and would therefore be very hard to access for a percutaneous drainage procedure. We continued antibiotics with Cipro and Flagyl, and his abdominal exam improved. He will be discharged on ciprofloxacin and flagyl to finish a 14 day course on ___. Transplant surgery's final recommendations remain that he is too high risk for CCY. Follow up with them as needed. #Leukopenia: As leukocytosis related to acute cholecystitis resolved, the patient became leukopenic to a nadir of 1.9 - differential mostly neutropenia and lymphopenia. Our team was unsure of the patient's baseline and considered antibiotic-associated leukopenia. Patient's leukopenia improved to 2.8 upon discharge. Will need repeat CBC on outpatient basis to follow up. # Cirrhosis: History of HE, variceal hemorrhage s/p banding. No history of SBP. Likely hemochromatosis/EtOH-induced. Labs showing coagulopathy with decreased PLTs and elevated INR. Imaging showing a congested abdomen from portal hypertension. Hepatology consulted and an extensive work up was ordered. AMA negative, Anti-smooth Negative, ___ negative, Hep B negative, Hep C negative, HIV negative. Patient had a paracentesis with the following results: WBC 86, RBC 475, Total protein 1.1, LDH 45, glucose 124, LDH 45, Albumin 0.6. No need for prophylactic or active SBP antibiotics. Patient was started on Lasix 20mg and spironolactone 50mg qd with a stable creatinine. Patient will be discharged on his home regimen of lactulose. #Bright red blood per rectum - scant BRBPR and was started on PPI/octreotide. Hepatology evaluated patient and given stable H&H and blood only while wiping, it was determined that scant blood most likely ___ hemorrhoids. PPI/octreotide subsequently discontinued. No further acute events and stable H&H upon discharge. CHRONIC ISSUES: =============== #Alcoholism - He has an extensive history of delirium tremens and was maintained on his seizure prophylaxis medications Keppra, folic acid, and thiamine. #DMT2: no home regimen. Was placed on SSI and ___ QACHS. Did not require insulin doses consistently. Will discharge without medications. Will follow up with PCP regarding need for medications or not. #Portal hypertension - Nadolol was initially held given his GI bleed and resumed when hemodynamically stable. Will discharge with home regimen dosing. #Behavioral health: on jail record review, was on quetiapine, sertraline, and trazodone which was continued during hospital stay. No acute events. Will be discharged on this regimen. #Seizure disorder: continued home regimen of LevETIRAcetam 750 mg PO BID with no changes upon discharge. No acute events. TRANSITIONAL ISSUES: ==================== []Will need to establish care with ___ clinic for cirrhosis management as follows (appointment scheduled as above) []Variceal screening EGD in outpatient setting given history of variceal banding []Hepatocellular carcinoma surveillance q6 months []Will need HBV vaccination on outpatient basis []Follow up CBC on next physician visit as patient was leukopenic upon discharge []If develops worsening abdominal pain, follow up with transplant surgery (contact number ___ [] Complete antibiotic treatment course for cholecystitis with Cipro/Flagyl to end ___ [] Discharge weight: 98.7 kg (217.59 lb) NEW MEDICATIONS: ================ Ciprofloxacin 500mg one tab two times a day. Finish on ___ Metronidazole 500mg one tab three times a day. Finish on ___ Furosemide 20mg one tab daily Spironolactone 50mg one tab daily CHANGED MEDICATION DOSING TO: ============================= None Stopped Medications: ==================== None -Code Status: full code confirmed -Emergency Contact: ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. LevETIRAcetam 750 mg PO BID 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 3. Sertraline 50 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. TraZODone 50 mg PO QHS 6. QUEtiapine Fumarate 100 mg PO QHS 7. Famotidine 20 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Nadolol 20 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Thiamine 100 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*11 Tablet Refills:*0 4. QUEtiapine Fumarate 100 mg PO QHS 5. Sertraline 50 mg PO DAILY 6. Spironolactone 50 mg PO DAILY RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 7. TraZODone 50 mg PO QHS 8. FoLIC Acid 1 mg PO DAILY 9. Lactulose 30 mL PO TID 10. LevETIRAcetam 750 mg PO BID 11. Lisinopril 5 mg PO DAILY 12. Magnesium Oxide 400 mg PO BID 13. Nadolol 20 mg PO DAILY 14. Omeprazole 40 mg PO BID 15. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================== -Acute cholecystitis -Leukopenia -Hypotension SECONDARY DIAGNOSES: ==================== -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 pleasure taking care of you here at the ___ ___. Why did you come to the hospital? -You were concerned about your fever and abdominal pain What did you receive in the hospital? -You had multiple blood tests and imaging which revealed you had an infected gallbladder, for which you received antibiotics. Your abdominal pain significantly improved during your hospital stay. -You were seen by the surgery and procedural team who said you were too high risk to have your gallbladder removed during your hospitalization. -We drew fluid from your abdomen which did not reveal an infection, which was reassuring. -You were seen by the liver specialists who recommended medications for your cirrhosis which you will go home on as well. What should you do when you leave the hospital? -You should continue taking your medications as described below -It is VERY IMPORTANT that you establish care with the liver specialist who will screen for the development of liver disease complications in addition to managing your cirrhosis -It will be important for you to follow up with your primary care physician as well. NEW MEDICATIONS: ================ Ciprofloxacin 500mg one tab two times a day. Finish on ___ Metronidazole 500mg one tab three times a day. Finish on ___ Furosemide 20mg one tab daily Spironolactone 50mg one tab daily CHANGED MEDICATION DOSING TO: ============================= None Stopped Medications: ==================== None Followup Instructions: ___
[ "K810", "D689", "K766", "K7030", "I959", "Z87820", "I10", "E785", "F419", "E119", "D72819", "K649", "G40909" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fevers, abdominal Pain Major Surgical or Invasive Procedure: Paracentesis [MASKED] History of Present Illness: [MASKED] y/o male with a history alcoholism c/b DT, siezure disorder, TBI s/p SAH after a fall, alcoholic cirrhosis c/b known varices s/p banding in [MASKED] and diabetes presents with fever and abdominal pain to OSH from jail. At [MASKED] he had a: RUQ US - gallbladder thickening c/w liver disease, no stones, no obstruction, +cirrhosis CT a/p - cirrhosis with small amount of ascites, diffuse stranding; GB wall edema could be secondary to cirrhosis and third-spacing, no definitive stones, could do HIDA for definitive r/o cholecystitis; diffuse colonic wall edema, more stranding around ascending colon, could represent colitis patient received zosyn, on third liter of IVF borderline blood pressures in 90's, tachcyardic to 110's Started on peripheral levophed He was transferred to [MASKED] because of cirrhosis history. In the [MASKED], initial vitals: 7 [MASKED] 96% RA Was started on protonix, octreotide, vancomycin. He was evaluated by GI- will follow no need for emergent scope given stable hemodynamics ACS- who requested he be seen by transplant Transplant - who will continue to follow but recommends EGD and [MASKED] Rectal was positive for blood. neg melena. Of note he was admitted to [MASKED] in [MASKED] with BRBPR and left before being scoped because he had a court date. He was also recently admitted to [MASKED] in [MASKED] with bilateral PNA, metabolic encephalopathy. On transfer, vitals were:2 99.4 110 100/52 18 97% RA On arrival to the MICU, patient was accompanied by security gaurds. He states that he started having abdominal pain [MASKED] sharp in the RUQ extending up and down the flank shortly after lunch. Constant in nature not made better or worse with movement. Associated with lightheadedness when he stands up. Denies f/c/cp/sob/n/v/orthopnea/leg swelling. This became worse after dinner which sent him into the hospital. Reports scant blood on TP after normal brown stools, no melena. Past Medical History: hemochromatosis HTN HLD anxiety Lyme Hepatitis alcoholic insomnia seizure pulmonary nodule diabetes type two Social History: [MASKED] Family History: Mother had diabetes-now deceased. Father is deceased. No family history of liver disease or cancer. Physical Exam: ========================== ADMISSION PHYSICAL ========================== Vitals: T:98.4 BP:118/67 P:80 R:22 O2:97% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: obese with spider angioma in the epigastrum TTP over the diffusely localizing over the RUQ, hepatomegaly no splenomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash, no jaundice NEURO: CN [MASKED] intact, no asterixis, [MASKED] strength bilaterally ACCESS: Left femoral ========================== DISCHARGE PHYSICAL ========================== Vital Signs: 98.1 98 / 46 85 16 95ra General: Alert, orientedx3 HEENT: Sclera anicteric, EOMI Lungs: CTA bilaterally CV: rrr, holosystolic murmur II/VI Abdomen: murphys sign not present, bowel sounds present, mild discomfort upon palpation of RUQ, improved since yesterday Ext: Warm, well perfused Pertinent Results: ========================== ADMISSION LABS ========================== [MASKED] 02:00AM BLOOD WBC-8.1 RBC-3.45* Hgb-9.8* Hct-30.6* MCV-89 MCH-28.4 MCHC-32.0 RDW-17.8* RDWSD-58.2* Plt Ct-68* [MASKED] 06:41AM BLOOD WBC-16.5*# RBC-3.45* Hgb-9.8* Hct-31.3* MCV-91 MCH-28.4 MCHC-31.3* RDW-17.7* RDWSD-58.6* Plt Ct-66* [MASKED] 02:00AM BLOOD Neuts-77* Bands-10* Lymphs-1* Monos-10 Eos-0 Baso-0 [MASKED] Metas-2* Myelos-0 AbsNeut-7.05* AbsLymp-0.08* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.00* [MASKED] 06:41AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND Baso-PND AbsNeut-PND AbsLymp-PND AbsMono-PND AbsEos-PND AbsBaso-PND [MASKED] 02:00AM BLOOD [MASKED] PTT-36.7* [MASKED] [MASKED] 02:00AM BLOOD Plt Smr-VERY LOW Plt Ct-68* [MASKED] 06:41AM BLOOD [MASKED] PTT-37.1* [MASKED] [MASKED] 06:41AM BLOOD Plt Ct-66* [MASKED] 02:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ [MASKED] 02:00AM BLOOD Glucose-71 UreaN-11 Creat-0.9 Na-139 K-3.1* Cl-107 HCO3-18* AnGap-17 [MASKED] 02:00AM BLOOD ALT-28 AST-46* AlkPhos-106 TotBili-3.0* DirBili-PND [MASKED] 02:00AM BLOOD cTropnT-<0.01 [MASKED] 02:00AM BLOOD Lipase-55 [MASKED] 02:00AM BLOOD Albumin-2.7* Calcium-8.0* Phos-2.4* Mg-1.3* [MASKED] 05:07AM BLOOD [MASKED] pO2-49* pCO2-31* pH-7.38 calTCO2-19* Base XS--5 [MASKED] 06:54AM BLOOD Type-CENTRAL VE Temp-36.7 pO2-49* pCO2-31* pH-7.38 calTCO2-19* Base XS--5 Intubat-NOT INTUBA [MASKED] 02:25AM BLOOD Lactate-3.5* [MASKED] 05:07AM BLOOD Lactate-4.5* [MASKED] 06:54AM BLOOD Lactate-4.3* K-3.4 [MASKED] 06:54AM BLOOD freeCa-1.05* [MASKED] 05:07AM BLOOD O2 Sat-81 ========================== DISCHARGE LABS ========================== [MASKED] 08:12AM BLOOD WBC-2.8* RBC-3.60* Hgb-9.9* Hct-32.1* MCV-89 MCH-27.5 MCHC-30.8* RDW-18.3* RDWSD-59.0* Plt Ct-82* [MASKED] 07:46AM BLOOD Neuts-59.3 [MASKED] Monos-13.3* Eos-1.3 Baso-0.4 Im [MASKED] AbsNeut-1.38* AbsLymp-0.59* AbsMono-0.31 AbsEos-0.03* AbsBaso-0.01 [MASKED] 08:12AM BLOOD [MASKED] PTT-40.7* [MASKED] [MASKED] 08:12AM BLOOD Glucose-74 UreaN-9 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-22 AnGap-15 [MASKED] 08:12AM BLOOD ALT-14 AST-31 AlkPhos-79 TotBili-2.5* [MASKED] 08:12AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.7 ========================== OTHER IMPORTANT LABS ========================== [MASKED] 01:24PM ASCITES WBC-86* RBC-475* Polys-24* Lymphs-38* [MASKED] Mesothe-5* Macroph-33* [MASKED] 01:24PM ASCITES TotPro-1.1 Glucose-124 LD(LDH)-45 Albumin-0.6 [MASKED] 08:03AM BLOOD calTIBC-181* Ferritn-64 TRF-139* [MASKED] 08:03AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative HAV Ab-Positive [MASKED] 08:03AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [MASKED] 08:03AM BLOOD [MASKED] [MASKED] 08:03AM BLOOD HIV Ab-Negative [MASKED] 02:00AM BLOOD Lipase-55 [MASKED] 02:00AM BLOOD cTropnT-<0.01 ========================== IMAGING ========================== [MASKED] CT A/P IMPRESSION: 1. Diffuse colonic wall edema could be secondary to portal hypertensive colopathy. However, there is relative increased fat stranding around the ascending colon and cecum as well as hyperemia that is concerning for possible colitis particularly given the patient's symptoms on the right. 2. Cirrhotic liver with sequela of portal hypertension including recanalization of the umbilical vein common extensive varices (including gastric and esophageal), splenomegaly, and small volume ascites. Overall heterogeneous enhancement is likely related to cirrhosis, but cannot exclude focal lesions. If concern, nonurgent dedicated hepatic imaging could be considered. 3. Extensive gallbladder wall edema is likely the sequela of chronic liver disease given the absence significant gallbladder distention.However, this could be further evaluated with a HIDA scan, if clinically indicated. 4. Diverticulosis without evidence of diverticulitis. [MASKED] RUQ U/S IMPRESSION: 1. Cirrhotic liver with evidence of portal hypertension including a recanalized umbilical vein and small volume ascites. 2. Extensive gallbladder wall edema is likely related to chronic hepatic disease given the absence of significant gallbladder wall distension and cholelithiasis. If clinical concern, however, HIDA scan could be considered for further evaluation. [MASKED] CTA A/P IMPRESSION: 1. No evidence of mesenteric ischemia. 2. Cirrhotic-appearing liver with sequelae of portal hypertension including ascites, splenomegaly, colopathy, recanalization of the paraumbilical vein, and numerous collaterals as well as gastric varices. 3. Nonspecific diffuse colonic edema with surrounding fat stranding, likely from portal hypertensive colopathy, but concurrent colitis from infection or inflammation is probable. 4. No evidence of active hemorrhage on this exam. 5. Mild sigmoid diverticulosis. 6. Gallbladder edema is likely from third spacing and reactive in setting of liver disease with ascites. [MASKED] HIDA SCAN IMPRESSION: Abnormal hepatobiliary scan with delayed appearance of tracer into the gallbladder. At 4 hours minimal tracer is noted in the gallbladder fossa. Findings most consistent with chronic cholecystitis; however, the minimal tracer uptake in the gallbladder fossa at 4 hours and the appearance of edema on CT makes it difficult to entirely rule out acute cholecystitis. [MASKED] ABDOMINAL FLAT/UPRIGHT IMPRESSION: 1. Diffuse mild gaseous distention of the small bowel loops without abnormal dilation of small bowel nor large bowel suggests ileus. 2. Mild thickening of the wall of the transverse colon is consistent with known history of colitis. 3. No free intraperitoneal air seen on left lateral decubitus view. [MASKED] CXR IMPRESSION: No acute cardiopulmonary process or evidence pneumonia. Probable small pleural effusions bilaterally. [MASKED] RUQ ULTRASOUND IMPRESSION: 1. Cirrhosis with evidence of portal hypertension including splenomegaly, small to moderate volume ascites, and a recanalized umbilical vein. 2. Gallbladder wall edema is likely related to chronic hepatic disease given relative gallbladder [MASKED]. 3. Cholelithiasis. ========================== MICRO ========================== [MASKED] Blood cultures no growth x [MASKED] Urine culture no growth [MASKED] stool cultures C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. FECAL CULTURE - R/O VIBRIO (Final [MASKED]: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [MASKED]: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [MASKED]: NO E.COLI 0157:H7 FOUND. [MASKED] 1:24 pm PERITONEAL FLUID GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: BRIEF SUMMARY: ============== [MASKED], incarcerated with PMH of Alcohol Abuse (complicated by DTs/Seizure, sober since [MASKED], seizure disorder, h/o TBI, hemochromatosis, EtOH/HCV cirrhosis (c/b varices, banded in [MASKED], T2DM who presented initially to OSH with acute onset of fever and abdominal pain. Imaging showing mostly complications of portal hypertension but given acute onset of fevers, pain, lactate elevation, and bilirubin elevation was consistent with cholecystistis, confirmed on HIDA scan. Transplant surgery and internventional radiology were consulted who deemed patient too high risk to undergo invasive intervention. Cholecystitis was managed with antibiotics with adequate response. Patient was also seen hepatology who recommended outpatient establishment with hepatologist to continue care for his cirrhosis. ACUTE ISSUES: ============= # Acute cholecystitis: In the MICU, warm on exam with evidence of abdominal infection on CT and elevated total bilirubin concerning for cholangitis/cholecystitis. He was treated with albumin infusions and pressor support with levophed, while being started on Ciprofloxacin and Flagyl. Upon arrival from MICU, patient noted to have obvious rebound tenderness of exam. A flat and upright was negative for free air, HIDA scan showed minimal tracer uptake into the gallbladder at 4 hours. When placed in context with acute onset of fevers and abdominal pain and leukocytosis, we presumed a diagnosis of acute cholecystitis. Transplant surgery was consulted, who stated Mr. [MASKED] was too high risk for cholecystectomy. Interventional radiology was consulted, who stated the gallbladder was not particularly distended, and would therefore be very hard to access for a percutaneous drainage procedure. We continued antibiotics with Cipro and Flagyl, and his abdominal exam improved. He will be discharged on ciprofloxacin and flagyl to finish a 14 day course on [MASKED]. Transplant surgery's final recommendations remain that he is too high risk for CCY. Follow up with them as needed. #Leukopenia: As leukocytosis related to acute cholecystitis resolved, the patient became leukopenic to a nadir of 1.9 - differential mostly neutropenia and lymphopenia. Our team was unsure of the patient's baseline and considered antibiotic-associated leukopenia. Patient's leukopenia improved to 2.8 upon discharge. Will need repeat CBC on outpatient basis to follow up. # Cirrhosis: History of HE, variceal hemorrhage s/p banding. No history of SBP. Likely hemochromatosis/EtOH-induced. Labs showing coagulopathy with decreased PLTs and elevated INR. Imaging showing a congested abdomen from portal hypertension. Hepatology consulted and an extensive work up was ordered. AMA negative, Anti-smooth Negative, [MASKED] negative, Hep B negative, Hep C negative, HIV negative. Patient had a paracentesis with the following results: WBC 86, RBC 475, Total protein 1.1, LDH 45, glucose 124, LDH 45, Albumin 0.6. No need for prophylactic or active SBP antibiotics. Patient was started on Lasix 20mg and spironolactone 50mg qd with a stable creatinine. Patient will be discharged on his home regimen of lactulose. #Bright red blood per rectum - scant BRBPR and was started on PPI/octreotide. Hepatology evaluated patient and given stable H&H and blood only while wiping, it was determined that scant blood most likely [MASKED] hemorrhoids. PPI/octreotide subsequently discontinued. No further acute events and stable H&H upon discharge. CHRONIC ISSUES: =============== #Alcoholism - He has an extensive history of delirium tremens and was maintained on his seizure prophylaxis medications Keppra, folic acid, and thiamine. #DMT2: no home regimen. Was placed on SSI and [MASKED] QACHS. Did not require insulin doses consistently. Will discharge without medications. Will follow up with PCP regarding need for medications or not. #Portal hypertension - Nadolol was initially held given his GI bleed and resumed when hemodynamically stable. Will discharge with home regimen dosing. #Behavioral health: on jail record review, was on quetiapine, sertraline, and trazodone which was continued during hospital stay. No acute events. Will be discharged on this regimen. #Seizure disorder: continued home regimen of LevETIRAcetam 750 mg PO BID with no changes upon discharge. No acute events. TRANSITIONAL ISSUES: ==================== []Will need to establish care with [MASKED] clinic for cirrhosis management as follows (appointment scheduled as above) []Variceal screening EGD in outpatient setting given history of variceal banding []Hepatocellular carcinoma surveillance q6 months []Will need HBV vaccination on outpatient basis []Follow up CBC on next physician visit as patient was leukopenic upon discharge []If develops worsening abdominal pain, follow up with transplant surgery (contact number [MASKED] [] Complete antibiotic treatment course for cholecystitis with Cipro/Flagyl to end [MASKED] [] Discharge weight: 98.7 kg (217.59 lb) NEW MEDICATIONS: ================ Ciprofloxacin 500mg one tab two times a day. Finish on [MASKED] Metronidazole 500mg one tab three times a day. Finish on [MASKED] Furosemide 20mg one tab daily Spironolactone 50mg one tab daily CHANGED MEDICATION DOSING TO: ============================= None Stopped Medications: ==================== None -Code Status: full code confirmed -Emergency Contact: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. LevETIRAcetam 750 mg PO BID 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 3. Sertraline 50 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. TraZODone 50 mg PO QHS 6. QUEtiapine Fumarate 100 mg PO QHS 7. Famotidine 20 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Nadolol 20 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Thiamine 100 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*11 Tablet Refills:*0 4. QUEtiapine Fumarate 100 mg PO QHS 5. Sertraline 50 mg PO DAILY 6. Spironolactone 50 mg PO DAILY RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 7. TraZODone 50 mg PO QHS 8. FoLIC Acid 1 mg PO DAILY 9. Lactulose 30 mL PO TID 10. LevETIRAcetam 750 mg PO BID 11. Lisinopril 5 mg PO DAILY 12. Magnesium Oxide 400 mg PO BID 13. Nadolol 20 mg PO DAILY 14. Omeprazole 40 mg PO BID 15. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: ================== -Acute cholecystitis -Leukopenia -Hypotension SECONDARY DIAGNOSES: ==================== -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 pleasure taking care of you here at the [MASKED] [MASKED]. Why did you come to the hospital? -You were concerned about your fever and abdominal pain What did you receive in the hospital? -You had multiple blood tests and imaging which revealed you had an infected gallbladder, for which you received antibiotics. Your abdominal pain significantly improved during your hospital stay. -You were seen by the surgery and procedural team who said you were too high risk to have your gallbladder removed during your hospitalization. -We drew fluid from your abdomen which did not reveal an infection, which was reassuring. -You were seen by the liver specialists who recommended medications for your cirrhosis which you will go home on as well. What should you do when you leave the hospital? -You should continue taking your medications as described below -It is VERY IMPORTANT that you establish care with the liver specialist who will screen for the development of liver disease complications in addition to managing your cirrhosis -It will be important for you to follow up with your primary care physician as well. NEW MEDICATIONS: ================ Ciprofloxacin 500mg one tab two times a day. Finish on [MASKED] Metronidazole 500mg one tab three times a day. Finish on [MASKED] Furosemide 20mg one tab daily Spironolactone 50mg one tab daily CHANGED MEDICATION DOSING TO: ============================= None Stopped Medications: ==================== None Followup Instructions: [MASKED]
[]
[ "I10", "E785", "F419", "E119" ]
[ "K810: Acute cholecystitis", "D689: Coagulation defect, unspecified", "K766: Portal hypertension", "K7030: Alcoholic cirrhosis of liver without ascites", "I959: Hypotension, unspecified", "Z87820: Personal history of traumatic brain injury", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "E119: Type 2 diabetes mellitus without complications", "D72819: Decreased white blood cell count, unspecified", "K649: Unspecified hemorrhoids", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus" ]
10,052,047
27,883,252
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: ___ Trans catheter aortic valve replacement History of Present Illness: ___ with PMH significant for CAD s/p prior MI w/LAD angioplasty in ___ & CABG ___, HFrEF, Afib, RBBB, CKD, DM II, HTN, OSA (does not use CPAP) & prostate CA s/p prostatectomy in ___. He also has a history of severe AS and underwent recent cardiac catheterization at which time he was assessed by the cardiac surgery service and deemed high risk for surgery. He was admitted ___ following planned TAVR in the setting of symptoms of increased fatigue as well as a significant functional decline in the past few months. ___ Class: III Past Medical History: 1. CAD, AWMI ___, MLAD TO, PCI. (Symptoms: back/chest/LUE discomfort). CABG ___, LIMA-diag-LAD, SVG-R1, SVG-OM, EF 50%. 2. Hypertension/LVH (carvedilol, losartan, furosemide) 3. Obesity. BMI 35.6 4. Atrial fibrillation, CHADS2 3 (warfarin, TTR 47%). 5. CKD, mild: Creatinine 1.18 (___) 6. DM type 2, HbA1c 7.3 (7.18) Dr. ___ at ___. 7. Dyslipidemia TC133.TG246.H40.L44 (1.19). Rosuva 20. 8. Severe aortic stenosis, ___ 0.8 TTE 65.19 9. Right bundle branch block 10. HFpEF, chronic (furosemide) 11. Severe sleep-disordered breathing 12. Prostate cancer, prostatectomy ___. 13. Former tobacco use. 14. OSA without CPAP Social History: ___ Family History: Brother deceased, DM and CAD. Mother with stroke. Two sons are alive and well. Physical Exam: Admission Physical Examination: Subjective: +Nausea w/dry heaving in PACU following sip of water, improved w/Zofran, groin sites held manually during episode, no evidence of bleeding. Otherwise now denies pain/discomfort. VS: 114/56, 63, 22, 95% RA General: Alert, no acute distress, answering questions appropriately Cardiovascular: Normal rate, Irregular rhythm Respiratory: Lungs clear anterior/laterally, breathing non-labored Abdomen: Obese, Non-tender, Hypoactive BS Extremities: BLE warm with trace edema and palpable ___ pulses Skin: Warm, dry and intact Access: Bilateral groin access sites soft, non-tender with no evidence of active bleeding or hematoma EKG: AF w/RBBB + LAFB, rate 66, QRS 140 Discharge Physical Examination: Weight: 238 pounds General: Alert, oriented, no acute distress Cardiovascular: Normal rate, Irregular rhythm Respiratory: Lungs clear bilaterally, breathing non-labored Abdomen: Obese, Non-tender, +BS Extremities: BLE warm with trace edema and palpable ___ pulses Skin: L lower lateral torso with area of raised erythema extending to the thigh area without open areas, bleeding, drainage, pustules, blisters or vesicles. Rash has not exceeded the previously marked borders. Access: Bilateral groin access sites soft, non-tender with no evidence of active bleeding or hematoma, moderate ecchymosis Pertinent Results: ======== Imaging ======== Pre-TAVR TTE ___: Pre-TAVR: There is a small area of regional left ventricular systolic dysfunction with hypokinesis of the distal septum, anterior wall and apex (see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40%. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is moderate [2+] tricuspid regurgitation. POST-PROCEDURE: The ___ 3 TAVR prosthesis is well seated. Leaflets were not well seen but gradient is normal. There is a paravalvular jet of trace aortic regurgitation is seen. Post TAVR TTE ___: The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is a small to moderate area of regional left ventricular systolic dysfunction with hypokinesis to akinesis of the mid to distal septum and apical ___ of the left ventricle (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 40 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated with a mildly dilated descending aorta. A ___ 3 aortic valve bioprosthesis is present. The prosthesis is well seated with leaflets not well seen but normal gradient. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are not well seen. There is significant pulmonic regurgitation. The tricuspid valve leaflets are mildly thickened. There is moderate [2+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE ___ , the comparable findings are similar. In addition, pulmonary artery pressures are measured and are moderate to severely elevated. Thoracic aortic ___ are mildly dilated. ===== LABS ===== CBC- ___ 10:10AM BLOOD WBC-4.8 RBC-3.83* Hgb-11.9* Hct-37.2* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.3 RDWSD-51.0* Plt ___ ___ 06:08AM BLOOD WBC-5.4 RBC-3.54* Hgb-11.1* Hct-35.0* MCV-99* MCH-31.4 MCHC-31.7* RDW-14.2 RDWSD-51.7* Plt ___ ___ 07:45AM BLOOD WBC-4.7 RBC-3.56* Hgb-11.2* Hct-35.2* MCV-99* MCH-31.5 MCHC-31.8* RDW-14.4 RDWSD-52.5* Plt ___ COAG- ___ 10:10AM BLOOD ___ PTT-34.9 ___ ___ 06:08AM BLOOD ___ ___ 07:45AM BLOOD ___ PTT-33.4 ___ CHEM- ___ 10:10AM BLOOD Glucose-181* UreaN-23* Creat-1.5* Na-138 K-5.2 Cl-103 HCO3-23 AnGap-12 Calcium-9.1 Phos-3.9 Mg-2.1 ___ 06:08AM BLOOD Glucose-88 UreaN-24* Creat-1.4* Na-142 K-4.5 Cl-104 HCO3-25 AnGap-13 ___ 07:45AM BLOOD UreaN-25* Creat-1.4* Na-143 K-4.5 Cl-103 HCO3-27 AnGap-___ssessment/Plan: ___ admitted s/p planned TAVR ___ in the setting of severe aortic stenosis. # Severe Aortic Stenosis: s/p TAVR ___ with 29mm S3. New LAFB with pre-existing RBBB & underlying AF, rhythm remains stable. LAFB resolved before DC. Post-TAVR TTE today showing well seated valve, EF 40%, Peak/Mean gradients ___, ___ 1.5. - Anticoag plan: Warfarin/Aspirin - Resumed Carvedilol today - SH team f/u 1 month - SBE prophylaxis instructions on d/c # HFrEF: EF 40%; appears euvolemic - Resumed home Lasix, Losartan and Carvedilol # Rash: L lateral lower torso, pt feels r/t poison ___ as he was working outside several days ago prior to onset of pruritic rash, does not appear consistent with zoster or infection, particularly given the likely recent exposure to poison ___. He confirms that the rash is not painful and has improved in appearance since onset. Image uploaded to OMR on admission ___. - Topical hydrocortisone PRN for itching per pt request - Continue to monitor # Coronary Artery Disease: 3VD, patent grafts on cath ___ - Continue Aspirin, Rosuvastatin - Resumed Carvedilol & Losartan # Permanent Atrial fibrillation: pre-existing RBBB, new LAFB (resolved). INR 1.8 today. Managed by PCP ___ / ___ clinic. - Resume Warfarin at home dosing regimen, INR ___ - Resume Carvedilol today # Hypertension: stable - Resumed home Carvedilol & Losartan today # Hyperlipidemia - Continue Rosuvastatin # Non-Insulin Dependent Diabetes: - Continue home Glipizide & diabetic/consistent carb diet # Chronic kidney disease: Recent baseline Cr 1.3-1.4, Cr 1.5 on admission post-procedure, Today Cr 1.4 # GERD - Continue Pantoprazole # OSA: Does not wear CPAP - Continuous O2 sat monitoring while admitted # Emergency contact: Name of health care proxy: ___ ___: wife Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 75 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Warfarin 0.5 mg PO 4X/WEEK (___) 4. Rosuvastatin Calcium 20 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Aspirin 81 mg PO DAILY 8. GlipiZIDE XL 5 mg PO QAM 9. GlipiZIDE XL 10 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 1 mg PO 3X/WEEK (___) Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Furosemide 40 mg PO DAILY 4. GlipiZIDE XL 5 mg PO QAM 5. GlipiZIDE XL 10 mg PO QPM 6. Losartan Potassium 75 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Rosuvastatin Calcium 20 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Warfarin 0.5 mg PO 4X/WEEK (___) 11. Warfarin 1 mg PO 3X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: Aortic Stenosis HFpEF Coronary Artery Disease Hypertension Atrial Fibrillation Non-Insulin Dependent Diabetes Mellitus Dyslipidemia Rash Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (TAVR) to treat your aortic valve stenosis. Please continue all of your medications as prescribed including your Warfarin (Coumadin) as directed by your ___ clinic. Please have your INR checked on ___. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 238 pounds. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call ___. 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 ___ Heart Line 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: ___
[ "I350", "I5032", "I452", "I130", "I2510", "E1122", "N189", "I482", "E785", "K219", "G4733", "L237", "I252", "Z951", "Z9861", "E669", "Z87891", "Z8546", "Z6839", "Z006" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [MASKED] Trans catheter aortic valve replacement History of Present Illness: [MASKED] with PMH significant for CAD s/p prior MI w/LAD angioplasty in [MASKED] & CABG [MASKED], HFrEF, Afib, RBBB, CKD, DM II, HTN, OSA (does not use CPAP) & prostate CA s/p prostatectomy in [MASKED]. He also has a history of severe AS and underwent recent cardiac catheterization at which time he was assessed by the cardiac surgery service and deemed high risk for surgery. He was admitted [MASKED] following planned TAVR in the setting of symptoms of increased fatigue as well as a significant functional decline in the past few months. [MASKED] Class: III Past Medical History: 1. CAD, AWMI [MASKED], MLAD TO, PCI. (Symptoms: back/chest/LUE discomfort). CABG [MASKED], LIMA-diag-LAD, SVG-R1, SVG-OM, EF 50%. 2. Hypertension/LVH (carvedilol, losartan, furosemide) 3. Obesity. BMI 35.6 4. Atrial fibrillation, CHADS2 3 (warfarin, TTR 47%). 5. CKD, mild: Creatinine 1.18 ([MASKED]) 6. DM type 2, HbA1c 7.3 (7.18) Dr. [MASKED] at [MASKED]. 7. Dyslipidemia TC133.TG246.H40.L44 (1.19). Rosuva 20. 8. Severe aortic stenosis, [MASKED] 0.8 TTE 65.19 9. Right bundle branch block 10. HFpEF, chronic (furosemide) 11. Severe sleep-disordered breathing 12. Prostate cancer, prostatectomy [MASKED]. 13. Former tobacco use. 14. OSA without CPAP Social History: [MASKED] Family History: Brother deceased, DM and CAD. Mother with stroke. Two sons are alive and well. Physical Exam: Admission Physical Examination: Subjective: +Nausea w/dry heaving in PACU following sip of water, improved w/Zofran, groin sites held manually during episode, no evidence of bleeding. Otherwise now denies pain/discomfort. VS: 114/56, 63, 22, 95% RA General: Alert, no acute distress, answering questions appropriately Cardiovascular: Normal rate, Irregular rhythm Respiratory: Lungs clear anterior/laterally, breathing non-labored Abdomen: Obese, Non-tender, Hypoactive BS Extremities: BLE warm with trace edema and palpable [MASKED] pulses Skin: Warm, dry and intact Access: Bilateral groin access sites soft, non-tender with no evidence of active bleeding or hematoma EKG: AF w/RBBB + LAFB, rate 66, QRS 140 Discharge Physical Examination: Weight: 238 pounds General: Alert, oriented, no acute distress Cardiovascular: Normal rate, Irregular rhythm Respiratory: Lungs clear bilaterally, breathing non-labored Abdomen: Obese, Non-tender, +BS Extremities: BLE warm with trace edema and palpable [MASKED] pulses Skin: L lower lateral torso with area of raised erythema extending to the thigh area without open areas, bleeding, drainage, pustules, blisters or vesicles. Rash has not exceeded the previously marked borders. Access: Bilateral groin access sites soft, non-tender with no evidence of active bleeding or hematoma, moderate ecchymosis Pertinent Results: ======== Imaging ======== Pre-TAVR TTE [MASKED]: Pre-TAVR: There is a small area of regional left ventricular systolic dysfunction with hypokinesis of the distal septum, anterior wall and apex (see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40%. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is moderate [2+] tricuspid regurgitation. POST-PROCEDURE: The [MASKED] 3 TAVR prosthesis is well seated. Leaflets were not well seen but gradient is normal. There is a paravalvular jet of trace aortic regurgitation is seen. Post TAVR TTE [MASKED]: The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is a small to moderate area of regional left ventricular systolic dysfunction with hypokinesis to akinesis of the mid to distal septum and apical [MASKED] of the left ventricle (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 40 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated with a mildly dilated descending aorta. A [MASKED] 3 aortic valve bioprosthesis is present. The prosthesis is well seated with leaflets not well seen but normal gradient. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are not well seen. There is significant pulmonic regurgitation. The tricuspid valve leaflets are mildly thickened. There is moderate [2+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE [MASKED] , the comparable findings are similar. In addition, pulmonary artery pressures are measured and are moderate to severely elevated. Thoracic aortic [MASKED] are mildly dilated. ===== LABS ===== CBC- [MASKED] 10:10AM BLOOD WBC-4.8 RBC-3.83* Hgb-11.9* Hct-37.2* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.3 RDWSD-51.0* Plt [MASKED] [MASKED] 06:08AM BLOOD WBC-5.4 RBC-3.54* Hgb-11.1* Hct-35.0* MCV-99* MCH-31.4 MCHC-31.7* RDW-14.2 RDWSD-51.7* Plt [MASKED] [MASKED] 07:45AM BLOOD WBC-4.7 RBC-3.56* Hgb-11.2* Hct-35.2* MCV-99* MCH-31.5 MCHC-31.8* RDW-14.4 RDWSD-52.5* Plt [MASKED] COAG- [MASKED] 10:10AM BLOOD [MASKED] PTT-34.9 [MASKED] [MASKED] 06:08AM BLOOD [MASKED] [MASKED] 07:45AM BLOOD [MASKED] PTT-33.4 [MASKED] CHEM- [MASKED] 10:10AM BLOOD Glucose-181* UreaN-23* Creat-1.5* Na-138 K-5.2 Cl-103 HCO3-23 AnGap-12 Calcium-9.1 Phos-3.9 Mg-2.1 [MASKED] 06:08AM BLOOD Glucose-88 UreaN-24* Creat-1.4* Na-142 K-4.5 Cl-104 HCO3-25 AnGap-13 [MASKED] 07:45AM BLOOD UreaN-25* Creat-1.4* Na-143 K-4.5 Cl-103 HCO3-27 AnGap- ssessment/Plan: [MASKED] admitted s/p planned TAVR [MASKED] in the setting of severe aortic stenosis. # Severe Aortic Stenosis: s/p TAVR [MASKED] with 29mm S3. New LAFB with pre-existing RBBB & underlying AF, rhythm remains stable. LAFB resolved before DC. Post-TAVR TTE today showing well seated valve, EF 40%, Peak/Mean gradients [MASKED], [MASKED] 1.5. - Anticoag plan: Warfarin/Aspirin - Resumed Carvedilol today - SH team f/u 1 month - SBE prophylaxis instructions on d/c # HFrEF: EF 40%; appears euvolemic - Resumed home Lasix, Losartan and Carvedilol # Rash: L lateral lower torso, pt feels r/t poison [MASKED] as he was working outside several days ago prior to onset of pruritic rash, does not appear consistent with zoster or infection, particularly given the likely recent exposure to poison [MASKED]. He confirms that the rash is not painful and has improved in appearance since onset. Image uploaded to OMR on admission [MASKED]. - Topical hydrocortisone PRN for itching per pt request - Continue to monitor # Coronary Artery Disease: 3VD, patent grafts on cath [MASKED] - Continue Aspirin, Rosuvastatin - Resumed Carvedilol & Losartan # Permanent Atrial fibrillation: pre-existing RBBB, new LAFB (resolved). INR 1.8 today. Managed by PCP [MASKED] / [MASKED] clinic. - Resume Warfarin at home dosing regimen, INR [MASKED] - Resume Carvedilol today # Hypertension: stable - Resumed home Carvedilol & Losartan today # Hyperlipidemia - Continue Rosuvastatin # Non-Insulin Dependent Diabetes: - Continue home Glipizide & diabetic/consistent carb diet # Chronic kidney disease: Recent baseline Cr 1.3-1.4, Cr 1.5 on admission post-procedure, Today Cr 1.4 # GERD - Continue Pantoprazole # OSA: Does not wear CPAP - Continuous O2 sat monitoring while admitted # Emergency contact: Name of health care proxy: [MASKED] [MASKED]: wife Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 75 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Warfarin 0.5 mg PO 4X/WEEK ([MASKED]) 4. Rosuvastatin Calcium 20 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Aspirin 81 mg PO DAILY 8. GlipiZIDE XL 5 mg PO QAM 9. GlipiZIDE XL 10 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 1 mg PO 3X/WEEK ([MASKED]) Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Furosemide 40 mg PO DAILY 4. GlipiZIDE XL 5 mg PO QAM 5. GlipiZIDE XL 10 mg PO QPM 6. Losartan Potassium 75 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Rosuvastatin Calcium 20 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Warfarin 0.5 mg PO 4X/WEEK ([MASKED]) 11. Warfarin 1 mg PO 3X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: Aortic Stenosis HFpEF Coronary Artery Disease Hypertension Atrial Fibrillation Non-Insulin Dependent Diabetes Mellitus Dyslipidemia Rash Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (TAVR) to treat your aortic valve stenosis. Please continue all of your medications as prescribed including your Warfarin (Coumadin) as directed by your [MASKED] clinic. Please have your INR checked on [MASKED]. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 238 pounds. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call [MASKED]. 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] Heart Line 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]
[]
[ "I5032", "I130", "I2510", "E1122", "N189", "E785", "K219", "G4733", "I252", "Z951", "E669", "Z87891" ]
[ "I350: Nonrheumatic aortic (valve) stenosis", "I5032: Chronic diastolic (congestive) heart failure", "I452: Bifascicular block", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I482: Chronic atrial fibrillation", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "L237: Allergic contact dermatitis due to plants, except food", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z9861: Coronary angioplasty status", "E669: Obesity, unspecified", "Z87891: Personal history of nicotine dependence", "Z8546: Personal history of malignant neoplasm of prostate", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
10,052,193
26,526,599
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: morphine Attending: ___ Chief Complaint: Fall with R orbital fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female presents with right orbital fracture on CT from OSH and right knee pain after a fall this morning. The fall occurred at 2am while she was walking downstairs in her home. She fell forward on the last step and recalls hitting her knee and the right side of her face on the floor. The fall was not witnessed. She lives with her daughter's family, and they found her down immediately after the incident. She remembers the event and there are no reports of LOC by family members. She was taken to an OSH where CT imaging showed evidence of a right orbital fracture. Was referred to ___ to assess need for surgical intervention. She has no reported falls in the past. She has right knee pain ___, some pain on her right flank, and a headache. She denies nausea/vomiting. Past Medical History: Past Medical History: Diabetes HTN Arthritis Past Surgical History: Left knee surgery Cholecystectomy Cataract surgery Social History: ___ Family History: Non-contributory Physical Exam: Discharge Physical Exam: Gen: AAOx3, NAD, lying comfortably in bed HEENT: MMM, no scleral icterus ***** Resp: nl effort, CTABL, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops Abd: +BS, soft, ND, appropriately tender to palpation Ext: WWP, no edema, 2+ DP Physical examination upon discharge: ___ Pertinent Results: ___ 12:34AM GLUCOSE-198* UREA N-19 CREAT-1.3* SODIUM-137 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 ___ 12:34AM estGFR-Using this ___ 12:34AM WBC-10.7* RBC-3.70* HGB-9.8* HCT-32.4* MCV-88 MCH-26.5 MCHC-30.2* RDW-15.4 RDWSD-49.0* ___ 12:34AM NEUTS-79.2* LYMPHS-11.8* MONOS-6.5 EOS-1.1 BASOS-0.5 IM ___ AbsNeut-8.48* AbsLymp-1.26 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.05 ___ 12:34AM PLT COUNT-224 ___ 12:34AM ___ PTT-31.7 ___ ___ 09:28PM URINE HOURS-RANDOM ___ 09:28PM URINE HOURS-RANDOM ___ 09:28PM URINE UHOLD-HOLD ___ 09:28PM URINE GR HOLD-HOLD ___ 09:28PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 09:28PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 Imaging: Head CT at OSH showed right orbital fracture. CT of high lower extremity w/o contrast: 1. Moderate-to-large high-density joint effusion suggests the possibility of hemarthrosis. 2. No fracture identified. 3. Moderate-to-severe tricompartmental degenerative changes. CT Torso: NO traumatic injuries Assessment/Plan: ___ y/o female with right orbital fracture and right knee pain/swelling s/p fall w/o LOC while walking down the stairs this morning. No concern for neurological injury based on history and physical exam and thus no need for operative management. Right knee is tender with mild swelling, but there is no evidence of fracture on imaging. Plan to discharge home with c Brief Hospital Course: Ms. ___ is a ___ old woman who had fallen down stairs, landing on her right side. She was transferred to ___ on ___ from ___ for further management of a right orbital fracture and R knee swelling and pain. Ophthalmology was consulted and recommended sinus precautions for 1 week, including no nose blowing, no drinking out of straw, no smoking. They also recommended follow up with her regular ophthalmologist in 1 week for dilated fundus exam. She should also seek ophthalmic evaluation sooner as outpatient if she experiences new onset flashes/floaters, diplopia, decrease in vision or other significant ophthalmic concerns. A right lower extremity CT was obtained on ___, which showed knee joint effusion with possible hemarthrosis, no fracture, and severe tricompartmental degenerative changes. Orthopedic surgery was consulted and recommended ACE wrap to right knee for support, weight bearing as tolerated, follow up with PCP and follow up in ___ clinic as needed. On ___, the patient was reported to have a decreased urine output and was given additional intravenous fluids. She had kidney studies done and was reported to be in ___. Her creatinine peaked at 2.8. Her kidney function tests were measured and at the time of discharge her creatinine was 1.2 with a bun of 26. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet. She did have some bacteria in her urine but was asymptomatic. In preparation for discharge, she was evaluated by physical therapy who made recommendations for discharge to a rehabilitation facility where the patient could regain her strength and mobility. The patient was discharged on HD #5 in stable condition. Appointments for follow-up were made with the Plastic surgery service and with her primary care provider. Medications on Admission: Atenolol 25 mg PO DAILY Hypertension GlipiZIDE 5 mg PO BID MetFORMIN (Glucophage) 1000 mg PO BID NIFEdipine CR 30 mg PO DAILY Hypertension Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Heparin 5000 UNIT SC BID ___ d/c when patient ambulatory 3. Simethicone 40-80 mg PO QID:PRN bloating 4. TraMADol 25 mg PO Q6H:PRN pain 5. Atenolol 25 mg PO DAILY Hypertension 6. GlipiZIDE 5 mg PO BID 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. NIFEdipine CR 30 mg PO DAILY Hypertension 9. Omeprazole 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right orbital floor fracture Right knee effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for evaluation and treatment of your injuries after a fall. Please follow the instructions below to continue your recovery: •Apply ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on your face for 15 to 20 minutes every hour as directed. •Keep your head elevated: Keep you head above the level of your heart as often as you can. This will help decrease swelling and pain. Prop your head on pillows or blankets to keep it elevated comfortably. •Avoid putting pressure on your face: -Do not sleep on the injured side of your face. Pressure on the area of your injury may cause further damage. -Sneeze with your mouth open to decrease pressure on your broken facial bones. Too much pressure from a sneeze may cause your broken bones to move and cause more damage. -Try not to blow your nose because it may cause more damage if you have a fracture near your eye. The pressure from blowing your nose may pinch the nerve of your eye and cause permanent damage. Contact your primary healthcare provider ___: •You have double vision or you suddenly have problems with your eyesight. •You have questions or concerns about your condition or care. Return to the emergency department if: •You have clear or pinkish fluid draining from your nose or mouth. •You have numbness in your face. •You have worsening pain in your eye or face. •You suddenly have trouble chewing or swallowing. •You suddenly feel lightheaded and short of breath. •You have chest pain when you take a deep breath or cough. You may cough up blood. •Your arm or leg feels warmer, more tender, or more painful. It may look swollen and red. Regarding your knee injury: •Rest your knee so it can heal. Limit activities that increase your pain. •Ice can help reduce swelling. Wrap ice in a towel and put it on your knee for as long and as often as directed. •Compression with a brace or bandage can help reduce swelling. Use a brace or bandage only as directed. •Elevation helps decrease pain and swelling. Elevate your knee while you are sitting or lying down. Prop your leg on pillows to keep your knee above the level of your heart. Followup Instructions: ___
[ "S023XXA", "N179", "N390", "E119", "S02401A", "Z6841", "I10", "W109XXA", "Y92098", "M25461", "M1711", "R339", "R451", "E669" ]
Allergies: morphine Chief Complaint: Fall with R orbital fracture Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o female presents with right orbital fracture on CT from OSH and right knee pain after a fall this morning. The fall occurred at 2am while she was walking downstairs in her home. She fell forward on the last step and recalls hitting her knee and the right side of her face on the floor. The fall was not witnessed. She lives with her daughter's family, and they found her down immediately after the incident. She remembers the event and there are no reports of LOC by family members. She was taken to an OSH where CT imaging showed evidence of a right orbital fracture. Was referred to [MASKED] to assess need for surgical intervention. She has no reported falls in the past. She has right knee pain [MASKED], some pain on her right flank, and a headache. She denies nausea/vomiting. Past Medical History: Past Medical History: Diabetes HTN Arthritis Past Surgical History: Left knee surgery Cholecystectomy Cataract surgery Social History: [MASKED] Family History: Non-contributory Physical Exam: Discharge Physical Exam: Gen: AAOx3, NAD, lying comfortably in bed HEENT: MMM, no scleral icterus ***** Resp: nl effort, CTABL, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops Abd: +BS, soft, ND, appropriately tender to palpation Ext: WWP, no edema, 2+ DP Physical examination upon discharge: [MASKED] Pertinent Results: [MASKED] 12:34AM GLUCOSE-198* UREA N-19 CREAT-1.3* SODIUM-137 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 [MASKED] 12:34AM estGFR-Using this [MASKED] 12:34AM WBC-10.7* RBC-3.70* HGB-9.8* HCT-32.4* MCV-88 MCH-26.5 MCHC-30.2* RDW-15.4 RDWSD-49.0* [MASKED] 12:34AM NEUTS-79.2* LYMPHS-11.8* MONOS-6.5 EOS-1.1 BASOS-0.5 IM [MASKED] AbsNeut-8.48* AbsLymp-1.26 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.05 [MASKED] 12:34AM PLT COUNT-224 [MASKED] 12:34AM [MASKED] PTT-31.7 [MASKED] [MASKED] 09:28PM URINE HOURS-RANDOM [MASKED] 09:28PM URINE HOURS-RANDOM [MASKED] 09:28PM URINE UHOLD-HOLD [MASKED] 09:28PM URINE GR HOLD-HOLD [MASKED] 09:28PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 09:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 09:28PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 Imaging: Head CT at OSH showed right orbital fracture. CT of high lower extremity w/o contrast: 1. Moderate-to-large high-density joint effusion suggests the possibility of hemarthrosis. 2. No fracture identified. 3. Moderate-to-severe tricompartmental degenerative changes. CT Torso: NO traumatic injuries Assessment/Plan: [MASKED] y/o female with right orbital fracture and right knee pain/swelling s/p fall w/o LOC while walking down the stairs this morning. No concern for neurological injury based on history and physical exam and thus no need for operative management. Right knee is tender with mild swelling, but there is no evidence of fracture on imaging. Plan to discharge home with c Brief Hospital Course: Ms. [MASKED] is a [MASKED] old woman who had fallen down stairs, landing on her right side. She was transferred to [MASKED] on [MASKED] from [MASKED] for further management of a right orbital fracture and R knee swelling and pain. Ophthalmology was consulted and recommended sinus precautions for 1 week, including no nose blowing, no drinking out of straw, no smoking. They also recommended follow up with her regular ophthalmologist in 1 week for dilated fundus exam. She should also seek ophthalmic evaluation sooner as outpatient if she experiences new onset flashes/floaters, diplopia, decrease in vision or other significant ophthalmic concerns. A right lower extremity CT was obtained on [MASKED], which showed knee joint effusion with possible hemarthrosis, no fracture, and severe tricompartmental degenerative changes. Orthopedic surgery was consulted and recommended ACE wrap to right knee for support, weight bearing as tolerated, follow up with PCP and follow up in [MASKED] clinic as needed. On [MASKED], the patient was reported to have a decreased urine output and was given additional intravenous fluids. She had kidney studies done and was reported to be in [MASKED]. Her creatinine peaked at 2.8. Her kidney function tests were measured and at the time of discharge her creatinine was 1.2 with a bun of 26. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet. She did have some bacteria in her urine but was asymptomatic. In preparation for discharge, she was evaluated by physical therapy who made recommendations for discharge to a rehabilitation facility where the patient could regain her strength and mobility. The patient was discharged on HD #5 in stable condition. Appointments for follow-up were made with the Plastic surgery service and with her primary care provider. Medications on Admission: Atenolol 25 mg PO DAILY Hypertension GlipiZIDE 5 mg PO BID MetFORMIN (Glucophage) 1000 mg PO BID NIFEdipine CR 30 mg PO DAILY Hypertension Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Heparin 5000 UNIT SC BID [MASKED] d/c when patient ambulatory 3. Simethicone 40-80 mg PO QID:PRN bloating 4. TraMADol 25 mg PO Q6H:PRN pain 5. Atenolol 25 mg PO DAILY Hypertension 6. GlipiZIDE 5 mg PO BID 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. NIFEdipine CR 30 mg PO DAILY Hypertension 9. Omeprazole 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Right orbital floor fracture Right knee effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for evaluation and treatment of your injuries after a fall. Please follow the instructions below to continue your recovery: •Apply ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on your face for 15 to 20 minutes every hour as directed. •Keep your head elevated: Keep you head above the level of your heart as often as you can. This will help decrease swelling and pain. Prop your head on pillows or blankets to keep it elevated comfortably. •Avoid putting pressure on your face: -Do not sleep on the injured side of your face. Pressure on the area of your injury may cause further damage. -Sneeze with your mouth open to decrease pressure on your broken facial bones. Too much pressure from a sneeze may cause your broken bones to move and cause more damage. -Try not to blow your nose because it may cause more damage if you have a fracture near your eye. The pressure from blowing your nose may pinch the nerve of your eye and cause permanent damage. Contact your primary healthcare provider [MASKED]: •You have double vision or you suddenly have problems with your eyesight. •You have questions or concerns about your condition or care. Return to the emergency department if: •You have clear or pinkish fluid draining from your nose or mouth. •You have numbness in your face. •You have worsening pain in your eye or face. •You suddenly have trouble chewing or swallowing. •You suddenly feel lightheaded and short of breath. •You have chest pain when you take a deep breath or cough. You may cough up blood. •Your arm or leg feels warmer, more tender, or more painful. It may look swollen and red. Regarding your knee injury: •Rest your knee so it can heal. Limit activities that increase your pain. •Ice can help reduce swelling. Wrap ice in a towel and put it on your knee for as long and as often as directed. •Compression with a brace or bandage can help reduce swelling. Use a brace or bandage only as directed. •Elevation helps decrease pain and swelling. Elevate your knee while you are sitting or lying down. Prop your leg on pillows to keep your knee above the level of your heart. Followup Instructions: [MASKED]
[]
[ "N179", "N390", "E119", "I10", "E669" ]
[ "S023XXA: Fracture of orbital floor", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "E119: Type 2 diabetes mellitus without complications", "S02401A: Maxillary fracture, unspecified side, initial encounter for closed fracture", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "Y92098: Other place in other non-institutional residence as the place of occurrence of the external cause", "M25461: Effusion, right knee", "M1711: Unilateral primary osteoarthritis, right knee", "R339: Retention of urine, unspecified", "R451: Restlessness and agitation", "E669: Obesity, unspecified" ]
10,052,340
23,427,451
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Penicillins Attending: ___. Chief Complaint: New Atrial Fibrillation with Rapid Ventricular Response Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old lady with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, and non-obstructive CAD who presented via EMS for weakness, found to have tachycardia and concern for STEMI in the ambulance. Ms. ___ is accompanied by her son and grandson. Today, she was shopping with her grandson when she became short of breath, and initially went to rest in the car for a few minutes while he continued shopping. They went home and then she developed acutely a "funny feeling all over" and right-sided chest discomfort. She has difficulty describing this further. She did have shortness of breath at the time, as well as abdominal discomfort and nausea. She denied lightheadedness, presyncope, syncope, dizziness or radiation. She took a SL nitroglycerin and after her son noticed that she was very pale he called EMS at 2:50. On arrival, they found her to be normotensive but tachycardic to the 200s. She was given 100mg IV amiodarone with improvement in HR. Rhythm strip was concerning for STEMI in III and aVF and code STEMI activated. In the ambulance on the way to BI, she returned to feeling completely normal. On arrival to the ED, she stated she was feeling well, denied nausea and vomiting. She denies any history of arrhythmia or MI. She has never had an experience similar to that of today before. In the ED... - Initial vitals: T 98, HR 90, BP 139/87, RR 18, O2 97%RA - EKG: LLB, no sgarbossa criteria; New afib with rvr - Labs/studies notable for: CBC 6.9>-110.5/32.7-<216 BUN 23, Cr 1.3 (baseline) Trop < 0.01 VBG 7.32 | 48 Lactate 2.5 Serum tox notable for acetaminophen level of 14; o/w negative BNP 1647 (no baseline) Coags wnl CXR with mild pulmonary edema, possible retrocardiac opacification. - Patient was given: ASA 324 On arrival to the floor, she confirmed the above history and feels well without symptoms. Her last bowel movement was this morning. She denies any recent changes in medications, any recent illnesses, any recent travel. REVIEW OF SYSTEMS: Positives in HPI. Otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY - Constipation - Osteoarthritis - Hypothyroidism Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: ___ 1830 Temp: 97.9 PO BP: 117/68 HR: 99 RR: 18 O2 sat: 96% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple, thyroid midline and symmetric. No JVD at 30 degrees. CARDIAC: PMI located in ___ intercostal space, midclavicular line. NR, RR. Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm. No ___ edema. SKIN: No rashes. PULSES: ___ pulses 1+ bilaterally NEURO: Alert and Oriented x3. Some difficulties with counting backwards from 10. DISCHARGE PHYSICAL EXAM: ========================== 98.2 PO 152/75 57 20 95 Ra FSBG: 95 GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, No JVD at 90 degrees. CARDIAC: irregular rhythm, but regular rate. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NT, mildly distended. No HSM or tenderness. EXTREMITIES: Warm. No ___ edema. Varicose veins b/l lower extremities. SKIN: No rashes. PULSES: ___ pulses 1+ bilaterally NEURO: Alert and Oriented x3. Pertinent Results: ADMISSION LABS: ================== ___ 03:52PM WBC-6.9 RBC-3.49* HGB-10.5* HCT-32.7* MCV-94 MCH-30.1 MCHC-32.1 RDW-13.8 RDWSD-46.9* ___ 03:52PM NEUTS-65.1 ___ MONOS-10.4 EOS-2.3 BASOS-0.6 IM ___ AbsNeut-4.46 AbsLymp-1.45 AbsMono-0.71 AbsEos-0.16 AbsBaso-0.04 ___ 06:50PM BLOOD cTropnT-0.32* ___ 07:28AM BLOOD CK-MB-16* cTropnT-0.48* ___ 10:59PM BLOOD cTropnT-0.76* ___ 03:30PM BLOOD cTropnT-<0.01 ___ 03:37PM GLUCOSE-104 LACTATE-2.5* NA+-141 K+-4.5 CL--104 ___ 03:37PM PO2-28* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--2 COMMENTS-GREEN TOP ___ 03:37PM freeCa-1.16 ___ 03:30PM cTropnT-<0.01 ___ 03:30PM CK-MB-3 proBNP-1647* ___ 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-14 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:30PM ___ PTT-28.7 ___ ___ 03:30PM ___ DISCHARGE LABS: ==================== ___ 07:50AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.7* Hct-33.4* MCV-93 MCH-29.8 MCHC-32.0 RDW-14.0 RDWSD-47.5* Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD ___ PTT-28.3 ___ ___ 07:50AM BLOOD Glucose-91 UreaN-25* Creat-1.3* Na-139 K-4.4 Cl-103 HCO3-25 AnGap-11 ___ 07:50AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 PERTINENT OTHER STUDIES: =========================== ___ Cardiovascular TTE Report CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with a moderately increased/dilated cavity. There is mild global left ventricular hypokinesis. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. No thrombus or mass is seen in the left ventricle. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. An aortic coarctation cannot be fully excluded. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is a valvular jet of moderate [2+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate symmetric left ventricular hypertrophy with moderate cavity dilation and mild global systolic dysfunction. Moderate mitral regurgitation. Mild tricuspid regurgitation. Brief Hospital Course: Ms. ___ is a ___ y/o F with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, hypothyroidism, and non-obstructive CAD who presented via EMS for weakness, found to have atrial fibrillation with RVR, asymptomatic on arrival to ___. # CORONARIES: Unknown # PUMP: EF 40-45% # RHYTHM: Irregularly irregular ACUTE ISSUES ============ # Paroxysmal Atrial Fibrillation with RVR # Non sustained ventricular tachycardia versus Afib with Aberrancy Presented with weakness, dyspnea with HR 200s with initiation of amiodarone gtt by EMS while en route to ___. No history of known atrial fibrillation. Her hospital course was c/b WCT with rates up to 180s concerning for atrial fibrillation with aberrancy vs. ventricular tachycardia. She was monitored on telemetry which was notable for frequent episodes of Non sustained VT as well as intermittent conversion to sinus rhythm. She was initiated on metoprolol PO with ultimate uptitration to 37.5mg every 6 hours. Her blood pressure and heart rates tolerated this well. She was started on a heparin gtt for CHADS-VASc of 5 without significant bleeding history and transitioned to apixaban 2.5 mg BID prior to discharge (secondary to fluctuating renal function per pharmacy). TTE was performed without evidence of focal wall motion abnormalities. # Troponemia Presented with initial concern for STEMI by EMS due to STE in III, aVF. On arrival she was noted to be asymptomatic with LBBB with negative sgarbossa and these elevations were felt to be more likely consistent with early repolarization or demand in setting of tachyarrhythmia. Initial trop negative x 1, however then peaked at 0.76 in the absence of symptoms. She reportedly had a cardiac catheterization at ___ ___ years ago with evidence of non-obstructive CAD per family report. Records were requested from ___ daily, but did not arrive. Her troponemia was felt to most likely be due to demand ischemia in the setting of rapid atrial fibrillation, and in discussion with patient and her son, cardiac catheterization would not be consistent with her goals of care at this time. She was started on aspirin 81 mg daily, and will continue on statin, metoprolol, and imdur. # Heart failure with reduced ejection fraction On arrival, patient was dyspneic while in a-fib with RVR, with elevated BNP, pulmonary edema on CXR. She appeared euvolemic on exam. TTE was obtained with evidence of mild GLOBAL left ventricular hypokinesis, EF 40-45%. TSH nl. Was given intermittent iv diuresis. Discharged on 20mg furosemide PO daily, metoprolol, imdur (home med), statin (home med) CHRONIC ISSUES ============== # Hypothyroidism TSH wnl at 0.63 at last appointment. Continued home synthroid. # CKD Cr 1.32 and eGFR 39 at last PCP ___. Cr remained 1.2-1.4 during admission. # Normocytic Anemia Hb 11.8 with MCV 92.4 at last PCP ___. RDW not elevated. Hgb ranged between ___ during admission without evidence of active bleeding. # Osteoarthritis - Continue Tylenol prn # Hypertension - Continued imdur # HLD - Continued pravastatin TRANSITIONAL ISSUES =================== #discharge weight: 99.57 kg (219.51 lb) #d/c BUN/Cr: ___ [] will need close monitoring of weights while initiating Lasix and chem 7 chem check. Will need to check labs ___ [] Started Aspirin 81mg EC daily [] has f/u with ___ cardiology [] Consider cardiac stress test as outpatient [] consider holter monitor/ziopatch to determine NSVT vs Aberrant afib and overall burden of episodes # CODE: Ok to resuscitate, DNI. - to be discussed with each admission as appropriate. Made aware of conflict between # CONTACT: Son/HCP ___ (___) ___ time 40 min Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Psyllium Powder 1 PKT PO DAILY 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 5. Vitamin D 1000 UNIT PO DAILY 6. LOPERamide 2 mg PO 8X/DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*1 5. LOPERamide 2 mg PO QID:PRN constipation 6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Psyllium Powder 1 PKT PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13.Outpatient Lab Work Dx: Systolic Heart Failure; ICD 10: I50.2 Labs: chem 10 For/By: ___ Attention: ___, MD Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Atrial fibrillation Troponemia Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___. Why was I here? - You came to the hospital because you were feeling weak - You were found to have an abnormal heart rhythm called atrial fibrillation with fast heart rates What was done while I was here? - You were started on a medication called metoprolol to help with your heart rates - You were also started on a medication called apixaban which is a blood thinner - You had an ultrasound of your heart which showed it wasn't pumping as well as it could be, but the medications you were already on and the new medications we started for you help with this. What should I do when I get home? - Please take all of your medications as prescribed and attend all of your follow up appointments, as listed below. Please review this list carefully and you MUST bring this list and this documentation with you to your upcoming appointments that we have made for you with Dr. ___ here at ___ Cardiology. - You should weigh yourself first thing every morning at the same time. You may need to purchase a scale. You should call your primary care doctor if your weight goes up greater than three pounds between any two days or slowly goes up five pounds over a week or two. They may have to change your new medication, "furosemide" also known as "Lasix." We wish you the best, Your ___ Care Team Followup Instructions: ___
[ "I130", "I5043", "I248", "I480", "N189", "I2510", "M1990", "E039", "I447", "E785", "Z87891", "D649" ]
Allergies: aspirin / Penicillins Chief Complaint: New Atrial Fibrillation with Rapid Ventricular Response Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old lady with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, and non-obstructive CAD who presented via EMS for weakness, found to have tachycardia and concern for STEMI in the ambulance. Ms. [MASKED] is accompanied by her son and grandson. Today, she was shopping with her grandson when she became short of breath, and initially went to rest in the car for a few minutes while he continued shopping. They went home and then she developed acutely a "funny feeling all over" and right-sided chest discomfort. She has difficulty describing this further. She did have shortness of breath at the time, as well as abdominal discomfort and nausea. She denied lightheadedness, presyncope, syncope, dizziness or radiation. She took a SL nitroglycerin and after her son noticed that she was very pale he called EMS at 2:50. On arrival, they found her to be normotensive but tachycardic to the 200s. She was given 100mg IV amiodarone with improvement in HR. Rhythm strip was concerning for STEMI in III and aVF and code STEMI activated. In the ambulance on the way to BI, she returned to feeling completely normal. On arrival to the ED, she stated she was feeling well, denied nausea and vomiting. She denies any history of arrhythmia or MI. She has never had an experience similar to that of today before. In the ED... - Initial vitals: T 98, HR 90, BP 139/87, RR 18, O2 97%RA - EKG: LLB, no sgarbossa criteria; New afib with rvr - Labs/studies notable for: CBC 6.9>-110.5/32.7-<216 BUN 23, Cr 1.3 (baseline) Trop < 0.01 VBG 7.32 | 48 Lactate 2.5 Serum tox notable for acetaminophen level of 14; o/w negative BNP 1647 (no baseline) Coags wnl CXR with mild pulmonary edema, possible retrocardiac opacification. - Patient was given: ASA 324 On arrival to the floor, she confirmed the above history and feels well without symptoms. Her last bowel movement was this morning. She denies any recent changes in medications, any recent illnesses, any recent travel. REVIEW OF SYSTEMS: Positives in HPI. Otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY - Constipation - Osteoarthritis - Hypothyroidism Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: [MASKED] 1830 Temp: 97.9 PO BP: 117/68 HR: 99 RR: 18 O2 sat: 96% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple, thyroid midline and symmetric. No JVD at 30 degrees. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. NR, RR. Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm. No [MASKED] edema. SKIN: No rashes. PULSES: [MASKED] pulses 1+ bilaterally NEURO: Alert and Oriented x3. Some difficulties with counting backwards from 10. DISCHARGE PHYSICAL EXAM: ========================== 98.2 PO 152/75 57 20 95 Ra FSBG: 95 GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, No JVD at 90 degrees. CARDIAC: irregular rhythm, but regular rate. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NT, mildly distended. No HSM or tenderness. EXTREMITIES: Warm. No [MASKED] edema. Varicose veins b/l lower extremities. SKIN: No rashes. PULSES: [MASKED] pulses 1+ bilaterally NEURO: Alert and Oriented x3. Pertinent Results: ADMISSION LABS: ================== [MASKED] 03:52PM WBC-6.9 RBC-3.49* HGB-10.5* HCT-32.7* MCV-94 MCH-30.1 MCHC-32.1 RDW-13.8 RDWSD-46.9* [MASKED] 03:52PM NEUTS-65.1 [MASKED] MONOS-10.4 EOS-2.3 BASOS-0.6 IM [MASKED] AbsNeut-4.46 AbsLymp-1.45 AbsMono-0.71 AbsEos-0.16 AbsBaso-0.04 [MASKED] 06:50PM BLOOD cTropnT-0.32* [MASKED] 07:28AM BLOOD CK-MB-16* cTropnT-0.48* [MASKED] 10:59PM BLOOD cTropnT-0.76* [MASKED] 03:30PM BLOOD cTropnT-<0.01 [MASKED] 03:37PM GLUCOSE-104 LACTATE-2.5* NA+-141 K+-4.5 CL--104 [MASKED] 03:37PM PO2-28* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--2 COMMENTS-GREEN TOP [MASKED] 03:37PM freeCa-1.16 [MASKED] 03:30PM cTropnT-<0.01 [MASKED] 03:30PM CK-MB-3 proBNP-1647* [MASKED] 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-14 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 03:30PM [MASKED] PTT-28.7 [MASKED] [MASKED] 03:30PM [MASKED] DISCHARGE LABS: ==================== [MASKED] 07:50AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.7* Hct-33.4* MCV-93 MCH-29.8 MCHC-32.0 RDW-14.0 RDWSD-47.5* Plt [MASKED] [MASKED] 07:50AM BLOOD Plt [MASKED] [MASKED] 07:50AM BLOOD [MASKED] PTT-28.3 [MASKED] [MASKED] 07:50AM BLOOD Glucose-91 UreaN-25* Creat-1.3* Na-139 K-4.4 Cl-103 HCO3-25 AnGap-11 [MASKED] 07:50AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 PERTINENT OTHER STUDIES: =========================== [MASKED] Cardiovascular TTE Report CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is moderate symmetric left ventricular hypertrophy with a moderately increased/dilated cavity. There is mild global left ventricular hypokinesis. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. No thrombus or mass is seen in the left ventricle. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. An aortic coarctation cannot be fully excluded. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is a valvular jet of moderate [2+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate symmetric left ventricular hypertrophy with moderate cavity dilation and mild global systolic dysfunction. Moderate mitral regurgitation. Mild tricuspid regurgitation. Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o F with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, hypothyroidism, and non-obstructive CAD who presented via EMS for weakness, found to have atrial fibrillation with RVR, asymptomatic on arrival to [MASKED]. # CORONARIES: Unknown # PUMP: EF 40-45% # RHYTHM: Irregularly irregular ACUTE ISSUES ============ # Paroxysmal Atrial Fibrillation with RVR # Non sustained ventricular tachycardia versus Afib with Aberrancy Presented with weakness, dyspnea with HR 200s with initiation of amiodarone gtt by EMS while en route to [MASKED]. No history of known atrial fibrillation. Her hospital course was c/b WCT with rates up to 180s concerning for atrial fibrillation with aberrancy vs. ventricular tachycardia. She was monitored on telemetry which was notable for frequent episodes of Non sustained VT as well as intermittent conversion to sinus rhythm. She was initiated on metoprolol PO with ultimate uptitration to 37.5mg every 6 hours. Her blood pressure and heart rates tolerated this well. She was started on a heparin gtt for CHADS-VASc of 5 without significant bleeding history and transitioned to apixaban 2.5 mg BID prior to discharge (secondary to fluctuating renal function per pharmacy). TTE was performed without evidence of focal wall motion abnormalities. # Troponemia Presented with initial concern for STEMI by EMS due to STE in III, aVF. On arrival she was noted to be asymptomatic with LBBB with negative sgarbossa and these elevations were felt to be more likely consistent with early repolarization or demand in setting of tachyarrhythmia. Initial trop negative x 1, however then peaked at 0.76 in the absence of symptoms. She reportedly had a cardiac catheterization at [MASKED] [MASKED] years ago with evidence of non-obstructive CAD per family report. Records were requested from [MASKED] daily, but did not arrive. Her troponemia was felt to most likely be due to demand ischemia in the setting of rapid atrial fibrillation, and in discussion with patient and her son, cardiac catheterization would not be consistent with her goals of care at this time. She was started on aspirin 81 mg daily, and will continue on statin, metoprolol, and imdur. # Heart failure with reduced ejection fraction On arrival, patient was dyspneic while in a-fib with RVR, with elevated BNP, pulmonary edema on CXR. She appeared euvolemic on exam. TTE was obtained with evidence of mild GLOBAL left ventricular hypokinesis, EF 40-45%. TSH nl. Was given intermittent iv diuresis. Discharged on 20mg furosemide PO daily, metoprolol, imdur (home med), statin (home med) CHRONIC ISSUES ============== # Hypothyroidism TSH wnl at 0.63 at last appointment. Continued home synthroid. # CKD Cr 1.32 and eGFR 39 at last PCP [MASKED]. Cr remained 1.2-1.4 during admission. # Normocytic Anemia Hb 11.8 with MCV 92.4 at last PCP [MASKED]. RDW not elevated. Hgb ranged between [MASKED] during admission without evidence of active bleeding. # Osteoarthritis - Continue Tylenol prn # Hypertension - Continued imdur # HLD - Continued pravastatin TRANSITIONAL ISSUES =================== #discharge weight: 99.57 kg (219.51 lb) #d/c BUN/Cr: [MASKED] [] will need close monitoring of weights while initiating Lasix and chem 7 chem check. Will need to check labs [MASKED] [] Started Aspirin 81mg EC daily [] has f/u with [MASKED] cardiology [] Consider cardiac stress test as outpatient [] consider holter monitor/ziopatch to determine NSVT vs Aberrant afib and overall burden of episodes # CODE: Ok to resuscitate, DNI. - to be discussed with each admission as appropriate. Made aware of conflict between # CONTACT: Son/HCP [MASKED] ([MASKED]) [MASKED] time 40 min Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Psyllium Powder 1 PKT PO DAILY 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 5. Vitamin D 1000 UNIT PO DAILY 6. LOPERamide 2 mg PO 8X/DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*1 5. LOPERamide 2 mg PO QID:PRN constipation 6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Psyllium Powder 1 PKT PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13.Outpatient Lab Work Dx: Systolic Heart Failure; ICD 10: I50.2 Labs: chem 10 For/By: [MASKED] Attention: [MASKED], MD Fax: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Atrial fibrillation Troponemia Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to take care of you at [MASKED]. Why was I here? - You came to the hospital because you were feeling weak - You were found to have an abnormal heart rhythm called atrial fibrillation with fast heart rates What was done while I was here? - You were started on a medication called metoprolol to help with your heart rates - You were also started on a medication called apixaban which is a blood thinner - You had an ultrasound of your heart which showed it wasn't pumping as well as it could be, but the medications you were already on and the new medications we started for you help with this. What should I do when I get home? - Please take all of your medications as prescribed and attend all of your follow up appointments, as listed below. Please review this list carefully and you MUST bring this list and this documentation with you to your upcoming appointments that we have made for you with Dr. [MASKED] here at [MASKED] Cardiology. - You should weigh yourself first thing every morning at the same time. You may need to purchase a scale. You should call your primary care doctor if your weight goes up greater than three pounds between any two days or slowly goes up five pounds over a week or two. They may have to change your new medication, "furosemide" also known as "Lasix." We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I130", "I480", "N189", "I2510", "E039", "E785", "Z87891", "D649" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "I248: Other forms of acute ischemic heart disease", "I480: Paroxysmal atrial fibrillation", "N189: Chronic kidney disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M1990: Unspecified osteoarthritis, unspecified site", "E039: Hypothyroidism, unspecified", "I447: Left bundle-branch block, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "D649: Anemia, unspecified" ]
10,052,395
23,421,657
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right sided facial fractures and nasal fractures Major Surgical or Invasive Procedure: ___: RIGHT ZM, Orbital Rim, Lateral Orbital Wall, Orbital Floor ORIF through R gingivobuccal and R Subtarsal incisions Closed nasal reduction History of Present Illness: Burden of injury: Right-sided ZMC, right-sided orbital floor, right-sided orbital rim, right-sided maxillary sinus, bilateral nasal bone fractures. ___ comes to the plastic surgery clinic for the first time since his injury initial evaluation in our emergency department by our resident staff. He denies any vision changes double vision difficulty with eye motion or pain with eye motion. He also denies any nasal drainage bleeding through the nose clear nasal drainage headaches or photophobia. He admits to some feeling of malocclusion on the right side but senses that he to that area in addition to the right mid face. Finally he does notice gross asymmetry in his nose first C shape deformity as well as flattening of his mid face. Past Medical History: PMH: L tibia fx PSH: cholecystectomy left tibial plateau fracture ORIF Social History: ___ Family History: noncontributory Physical Exam: ___ 0727 Temp: 98.0 PO BP: 114/76 HR: 73 RR: 18 O2 sat: 99% O2 delivery: RA ___ 0712 Pain Score: ___ ___ 0754 Dyspnea: 0 RASS: 0 Pain Score: ___ ___ Total Intake: 3164ml PO Amt: 600ml IV Amt Infused: 2564ml ___ Total Output: 2875ml Urine Amt: 2875ml Gen: NAD, A&Ox3, lying on stretcher. CV: RRR R: Breathing comfortably on room air. No wheezing. HEENT: Normocephalic. EOMI, PERRLA, TM, OPC moderate edema and ecchymosis. Incisions intact. Eye moves in all directions, mildly restricted in range. Visual acuity grossly intact. Continued infraorbital numbness. No malocclusion Facial width restored Pertinent Results: Final Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ year old man with facial fx s/p ORIF// evaluate facial fx and hardware- please reformat into 3D TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 16.8 cm; CTDIvol = 32.7 mGy (Head) DLP = 527.7 mGy-cm. Total DLP (Head) = 528 mGy-cm. COMPARISON: ___ outside noncontrast head CT. FINDINGS: Surgical hardware streak artifact limits examination. Patient is status post open reduction internal fixation of the right zygomatic arch with placement of plate and screws from the frontal processed to temporal process. 6 mm depression into the maxillary sinus of a 1.6 cm fragment is again noted. Fractures along the infratemporal surface are noted. Patient is also status post open reduction internal fixation of the fracture in the orbital floor with curved plate in place. Overall unchanged since prior are multiple nasal bone fractures, with 2 mm displacement to the left of the left nasal bone. In addition there is septal fracture and deviation the left. There is near complete opacification of the right maxillary sinus and mild mucosal thickening of the left maxillary sinus, grossly unchanged. Again seen mild mucosal thickening in the ethmoidal cells and right sphenoid sinus. There is soft tissue edema along the right side of the face extending slightly into the maxillary area. Trace nonspecific right mastoid air cell fluid is noted. Otherwise, bilateral mastoids appear preserved. The globes, extraocular muscles, optic nerves, and retrobulbar fat appear grossly preserved. The visualized upper aerodigestive tract appears preserved. The mandible and temporomandibular joints appear preserved. Right maxillary molar periapical lucency is noted (see 7:64; 03:16). IMPRESSION: 1. Surgical hardware streak artifact limits examination. 2. Postsurgical changes related to patient's known open reduction internal fixation of the multiple fractures involving the right zygomatic arch, floor of the right orbit. 3. Additional multiple grossly stable maxillofacial fractures as described. 4. Nonspecific grossly stable near complete opacification of right maxillary sinus compared to ___ prior exam, an additional paranasal sinus mucosal thickening as described. 5. Right maxillary molar periodontal disease as described. Brief Hospital Course: ___ was admitted to the Plastic Surgery service after surgery to repair multiple right sided facial fractures and closed nasal reduction Post operatively he had excellent visual acuity, extra-ocular motion, occlusion and stable R V2 parasthesia. Improved midfacial height and projection with CT showing stable hardware position He did well with regard to diet, pain control and medication tolerance and was discharged back to custody on post operative day 1 He has a follow up appointment at the plastic surgery clinic in 5-days for early interval check and suture removal Medications on Admission: see OMR Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*14 Tablet Refills:*0 3. Artificial Tears ___ DROP BOTH EYES TID RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1 %-0.3 % ___ drops bilateral eyes topical three times a day Disp #*1 Bottle Refills:*1 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15mL swish and spit twice a day Refills:*1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) cm both eyes four times a day Refills:*1 7. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP RIGHT EYE BID RX *prednisolone acetate 1 % 1 drop Right eye twice a day Refills:*1 8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: facial fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on ___ for repair of zygomaticomaxillay, Orbital Rim, Lateral Orbital Wall, and Orbital Floor ORIF. Please follow these discharge instructions: . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain . You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging . * Take prescription pain medications for pain not relieved by tylenol. * Take your antibiotic as prescribed. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. * Take eye drops and other medications as prescribed . Call the office IMMEDIATELY if you have any of the following: * Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). * A large amount of bleeding from the incision(s). * Fever greater than 101.5 oF * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Activities: * No strenuous activity * Exercise should be limited to walking; no lifting, straining, or excessive bending. * Unless directed by your physician, do not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen etc . Comments: * Please sleep on several pillows and try to keep your head elevated to help with drainage. * Please maintain SOFT diet (starting 72 hours after surgery, clear liquids until then) until your follow up clinic visit and you can ask your surgeon whether you can advance your diet at that time. * Please avoid blowing your nose. * Sneeze with your mouth open * Try to avoid sipping liquids through a straw * No smoking Followup Instructions: ___
[ "S0231XA", "S0240EA", "S022XXA", "S0281XA", "S0240CA", "J342", "X58XXXA", "Y939" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right sided facial fractures and nasal fractures Major Surgical or Invasive Procedure: [MASKED]: RIGHT ZM, Orbital Rim, Lateral Orbital Wall, Orbital Floor ORIF through R gingivobuccal and R Subtarsal incisions Closed nasal reduction History of Present Illness: Burden of injury: Right-sided ZMC, right-sided orbital floor, right-sided orbital rim, right-sided maxillary sinus, bilateral nasal bone fractures. [MASKED] comes to the plastic surgery clinic for the first time since his injury initial evaluation in our emergency department by our resident staff. He denies any vision changes double vision difficulty with eye motion or pain with eye motion. He also denies any nasal drainage bleeding through the nose clear nasal drainage headaches or photophobia. He admits to some feeling of malocclusion on the right side but senses that he to that area in addition to the right mid face. Finally he does notice gross asymmetry in his nose first C shape deformity as well as flattening of his mid face. Past Medical History: PMH: L tibia fx PSH: cholecystectomy left tibial plateau fracture ORIF Social History: [MASKED] Family History: noncontributory Physical Exam: [MASKED] 0727 Temp: 98.0 PO BP: 114/76 HR: 73 RR: 18 O2 sat: 99% O2 delivery: RA [MASKED] 0712 Pain Score: [MASKED] [MASKED] 0754 Dyspnea: 0 RASS: 0 Pain Score: [MASKED] [MASKED] Total Intake: 3164ml PO Amt: 600ml IV Amt Infused: 2564ml [MASKED] Total Output: 2875ml Urine Amt: 2875ml Gen: NAD, A&Ox3, lying on stretcher. CV: RRR R: Breathing comfortably on room air. No wheezing. HEENT: Normocephalic. EOMI, PERRLA, TM, OPC moderate edema and ecchymosis. Incisions intact. Eye moves in all directions, mildly restricted in range. Visual acuity grossly intact. Continued infraorbital numbness. No malocclusion Facial width restored Pertinent Results: Final Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: [MASKED] year old man with facial fx s/p ORIF// evaluate facial fx and hardware- please reformat into 3D TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 16.8 cm; CTDIvol = 32.7 mGy (Head) DLP = 527.7 mGy-cm. Total DLP (Head) = 528 mGy-cm. COMPARISON: [MASKED] outside noncontrast head CT. FINDINGS: Surgical hardware streak artifact limits examination. Patient is status post open reduction internal fixation of the right zygomatic arch with placement of plate and screws from the frontal processed to temporal process. 6 mm depression into the maxillary sinus of a 1.6 cm fragment is again noted. Fractures along the infratemporal surface are noted. Patient is also status post open reduction internal fixation of the fracture in the orbital floor with curved plate in place. Overall unchanged since prior are multiple nasal bone fractures, with 2 mm displacement to the left of the left nasal bone. In addition there is septal fracture and deviation the left. There is near complete opacification of the right maxillary sinus and mild mucosal thickening of the left maxillary sinus, grossly unchanged. Again seen mild mucosal thickening in the ethmoidal cells and right sphenoid sinus. There is soft tissue edema along the right side of the face extending slightly into the maxillary area. Trace nonspecific right mastoid air cell fluid is noted. Otherwise, bilateral mastoids appear preserved. The globes, extraocular muscles, optic nerves, and retrobulbar fat appear grossly preserved. The visualized upper aerodigestive tract appears preserved. The mandible and temporomandibular joints appear preserved. Right maxillary molar periapical lucency is noted (see 7:64; 03:16). IMPRESSION: 1. Surgical hardware streak artifact limits examination. 2. Postsurgical changes related to patient's known open reduction internal fixation of the multiple fractures involving the right zygomatic arch, floor of the right orbit. 3. Additional multiple grossly stable maxillofacial fractures as described. 4. Nonspecific grossly stable near complete opacification of right maxillary sinus compared to [MASKED] prior exam, an additional paranasal sinus mucosal thickening as described. 5. Right maxillary molar periodontal disease as described. Brief Hospital Course: [MASKED] was admitted to the Plastic Surgery service after surgery to repair multiple right sided facial fractures and closed nasal reduction Post operatively he had excellent visual acuity, extra-ocular motion, occlusion and stable R V2 parasthesia. Improved midfacial height and projection with CT showing stable hardware position He did well with regard to diet, pain control and medication tolerance and was discharged back to custody on post operative day 1 He has a follow up appointment at the plastic surgery clinic in 5-days for early interval check and suture removal Medications on Admission: see OMR Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*14 Tablet Refills:*0 3. Artificial Tears [MASKED] DROP BOTH EYES TID RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1 %-0.3 % [MASKED] drops bilateral eyes topical three times a day Disp #*1 Bottle Refills:*1 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15mL swish and spit twice a day Refills:*1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) cm both eyes four times a day Refills:*1 7. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP RIGHT EYE BID RX *prednisolone acetate 1 % 1 drop Right eye twice a day Refills:*1 8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: facial fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on [MASKED] for repair of zygomaticomaxillay, Orbital Rim, Lateral Orbital Wall, and Orbital Floor ORIF. Please follow these discharge instructions: . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain . You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging . * Take prescription pain medications for pain not relieved by tylenol. * Take your antibiotic as prescribed. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. * Take eye drops and other medications as prescribed . Call the office IMMEDIATELY if you have any of the following: * Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). * A large amount of bleeding from the incision(s). * Fever greater than 101.5 oF * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Activities: * No strenuous activity * Exercise should be limited to walking; no lifting, straining, or excessive bending. * Unless directed by your physician, do not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen etc . Comments: * Please sleep on several pillows and try to keep your head elevated to help with drainage. * Please maintain SOFT diet (starting 72 hours after surgery, clear liquids until then) until your follow up clinic visit and you can ask your surgeon whether you can advance your diet at that time. * Please avoid blowing your nose. * Sneeze with your mouth open * Try to avoid sipping liquids through a straw * No smoking Followup Instructions: [MASKED]
[]
[]
[ "S0231XA: Fracture of orbital floor, right side, initial encounter for closed fracture", "S0240EA: Zygomatic fracture, right side, initial encounter for closed fracture", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "S0281XA: Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture", "S0240CA: Maxillary fracture, right side, initial encounter for closed fracture", "J342: Deviated nasal septum", "X58XXXA: Exposure to other specified factors, initial encounter", "Y939: Activity, unspecified" ]
10,052,530
27,361,644
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Laparoscopy Appendectomy ___ History of Present Illness: Patient presents with 12 hours of acute abdominal pain. Symptoms began suddenly upon waking this AM. Pain was initially at periumbillical area but now radiated to his RLQ. Reports one episode of emesis and anorexia. Denies fever, chills, diarrhea, and urinary symptoms. Has not tried analgesics for symptoms. Upon evaluation. No acute distress. VSS. Abdomen soft, non-distended. He has localized tenderness with rebound at RLQ. Otherwise his abdomen is soft. Pain is reproducible with RLE extension. Also has psoas sign. No rovsing. Work up notable for leukocytosis to ___ with left shift. Imaging demonstrating inflamed retrocecal appendix without signs of perforation. Past Medical History: none Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 98.9, 60, 122/68, 16, 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Tenderness with localized rebound at RLQ. Otherwise is soft, nondistended, nontender. + psoas sign Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.8 PO 116 / 68 54 18 97 Ra GEN: Awake, alert, pleasant and interactive. CV: RRR PULM: Clear bilaterally. ABD: Soft, mildly tender incisionally as anticipated, mildly distended. EXT: Warm and dry. 2+ ___ pulses. NEURO: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 12:37PM BLOOD Neuts-91.3* Lymphs-4.3* Monos-3.2* Eos-0.2* Baso-0.5 Im ___ AbsNeut-13.96* AbsLymp-0.66* AbsMono-0.49 AbsEos-0.03* AbsBaso-0.07 ___ 12:37PM BLOOD WBC-15.3* RBC-4.99 Hgb-15.0 Hct-43.0 MCV-86 MCH-30.1 MCHC-34.9 RDW-12.5 RDWSD-38.6 Plt ___ ___ 12:37PM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-141 K-4.5 Cl-100 HCO3-24 AnGap-17 ___ 03:03AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 ___ 6:___BD & PELVIS WITH CONTRAST Clip # ___ IMPRESSION: Acute appendicitis without evidence of gross perforation. Brief Hospital Course: Mr. ___ is a ___ yo M who was admitted to the Acute care surgery Service on ___ with abdominal pain and found to have acute appendicitis on CT scan. Informed consent was obtained and the patient underwent laparoscopic appendectomy on ___. Please see operative report for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquid diet, on IV fluids, and IV dilaudid for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 4. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with abdominal pain and found to have an infection in your appendix. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
[ "K3580", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Laparoscopy Appendectomy [MASKED] History of Present Illness: Patient presents with 12 hours of acute abdominal pain. Symptoms began suddenly upon waking this AM. Pain was initially at periumbillical area but now radiated to his RLQ. Reports one episode of emesis and anorexia. Denies fever, chills, diarrhea, and urinary symptoms. Has not tried analgesics for symptoms. Upon evaluation. No acute distress. VSS. Abdomen soft, non-distended. He has localized tenderness with rebound at RLQ. Otherwise his abdomen is soft. Pain is reproducible with RLE extension. Also has psoas sign. No rovsing. Work up notable for leukocytosis to [MASKED] with left shift. Imaging demonstrating inflamed retrocecal appendix without signs of perforation. Past Medical History: none Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 98.9, 60, 122/68, 16, 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Tenderness with localized rebound at RLQ. Otherwise is soft, nondistended, nontender. + psoas sign Ext: No [MASKED] edema, [MASKED] warm and well perfused Discharge Physical Exam: VS: 97.8 PO 116 / 68 54 18 97 Ra GEN: Awake, alert, pleasant and interactive. CV: RRR PULM: Clear bilaterally. ABD: Soft, mildly tender incisionally as anticipated, mildly distended. EXT: Warm and dry. 2+ [MASKED] pulses. NEURO: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: [MASKED] 12:37PM BLOOD Neuts-91.3* Lymphs-4.3* Monos-3.2* Eos-0.2* Baso-0.5 Im [MASKED] AbsNeut-13.96* AbsLymp-0.66* AbsMono-0.49 AbsEos-0.03* AbsBaso-0.07 [MASKED] 12:37PM BLOOD WBC-15.3* RBC-4.99 Hgb-15.0 Hct-43.0 MCV-86 MCH-30.1 MCHC-34.9 RDW-12.5 RDWSD-38.6 Plt [MASKED] [MASKED] 12:37PM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-141 K-4.5 Cl-100 HCO3-24 AnGap-17 [MASKED] 03:03AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 [MASKED] 6: BD & PELVIS WITH CONTRAST Clip # [MASKED] IMPRESSION: Acute appendicitis without evidence of gross perforation. Brief Hospital Course: Mr. [MASKED] is a [MASKED] yo M who was admitted to the Acute care surgery Service on [MASKED] with abdominal pain and found to have acute appendicitis on CT scan. Informed consent was obtained and the patient underwent laparoscopic appendectomy on [MASKED]. Please see operative report for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquid diet, on IV fluids, and IV dilaudid for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 4. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital with abdominal pain and found to have an infection in your appendix. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "K3580: Unspecified acute appendicitis", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,052,597
20,894,008
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: sulfa drugs / shellfish derived Attending: ___ Chief Complaint: Left knee osteoarthritis Major Surgical or Invasive Procedure: Left total knee arthroplasty on ___ History of Present Illness: Mrs. ___ is ___ who presents with left knee arthritis. She presents for a left total knee arhtroplasty. Past Medical History: seizures as an infant, depression/anxiety, HLD, obesity Social History: ___ Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:18AM BLOOD WBC-8.1 RBC-2.74* Hgb-7.1* Hct-23.0* MCV-84 MCH-25.9* MCHC-30.9* RDW-16.6* RDWSD-50.5* Plt ___ ___ 07:28AM BLOOD WBC-10.6* RBC-3.15* Hgb-8.1* Hct-26.5* MCV-84 MCH-25.7* MCHC-30.6* RDW-16.9* RDWSD-51.9* Plt ___ ___ 06:20AM BLOOD WBC-10.0 RBC-3.16* Hgb-8.3* Hct-27.0* MCV-85 MCH-26.3 MCHC-30.7* RDW-16.9* RDWSD-52.6* Plt ___ ___ 06:18AM BLOOD Plt ___ ___ 07:28AM BLOOD Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-135 K-4.3 Cl-102 HCO3-22 AnGap-15 ___ 06:20AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: She was having increased pain on POD 1 so she was provided with x1 dose of oxycodone. She was having increased anxiety so she was provided night time dose of clonapin. She typically takes klonapin 0.5mg TID plus 1mg QHS, but patient reported that she takes more than this at home. On POD#2, she no longer showed signs of withdrawal. #Acute post operative blood loss anemia, Hct 23.0, POD#3, patient is asymptomatic with normal vital signs. PLEASE DO NOT PERFORM LABS UNLESS PATIENT BECOMES SYMPTOMATIC!!!! PLEASE CALL THE ORTHOPAEDIC SURGERY DEPARTMENT PRIOR TO INIATING WORK UP OR SENDING TO THE EMERGENCY DEPARTMENT!!!! Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The surgical dressing was changed and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 crutches at all times for 6 weeks. Ms. ___ is discharged to rehab in stable condition. Medications on Admission: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. ClonazePAM 0.5 mg PO TID:PRN anxiety 4. DULoxetine 60 mg PO DAILY 5. Hydroxychloroquine Sulfate 300 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 5. Senna 8.6 mg PO BID 6. ClonazePAM 1 mg PO QHS 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 8. BuPROPion XL (Once Daily) 300 mg PO DAILY 9. ClonazePAM 0.5 mg PO TID:PRN anxiety 10. DULoxetine 60 mg PO DAILY 11. Hydroxychloroquine Sulfate 300 mg PO DAILY 12. Lisinopril 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, please hold this medication until you have completed your one-month course of anticoagulation medication or unless cleared by your physician. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at follow-up appointment approximately two 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 at all times for 6 weeks. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Assistive device x 6 weeks post-op (i.e., 2 crutches, walker) Mobilize frequently Treatments Frequency: DSD daily prn drainage Ice and elevate *Staples will be removed at your first post-operative visit* Followup Instructions: ___
[ "M1712", "D62", "E6601", "Z6838", "F329", "F419", "E785", "F1290" ]
Allergies: sulfa drugs / shellfish derived Chief Complaint: Left knee osteoarthritis Major Surgical or Invasive Procedure: Left total knee arthroplasty on [MASKED] History of Present Illness: Mrs. [MASKED] is [MASKED] who presents with left knee arthritis. She presents for a left total knee arhtroplasty. Past Medical History: seizures as an infant, depression/anxiety, HLD, obesity Social History: [MASKED] Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:18AM BLOOD WBC-8.1 RBC-2.74* Hgb-7.1* Hct-23.0* MCV-84 MCH-25.9* MCHC-30.9* RDW-16.6* RDWSD-50.5* Plt [MASKED] [MASKED] 07:28AM BLOOD WBC-10.6* RBC-3.15* Hgb-8.1* Hct-26.5* MCV-84 MCH-25.7* MCHC-30.6* RDW-16.9* RDWSD-51.9* Plt [MASKED] [MASKED] 06:20AM BLOOD WBC-10.0 RBC-3.16* Hgb-8.3* Hct-27.0* MCV-85 MCH-26.3 MCHC-30.7* RDW-16.9* RDWSD-52.6* Plt [MASKED] [MASKED] 06:18AM BLOOD Plt [MASKED] [MASKED] 07:28AM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-135 K-4.3 Cl-102 HCO3-22 AnGap-15 [MASKED] 06:20AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: She was having increased pain on POD 1 so she was provided with x1 dose of oxycodone. She was having increased anxiety so she was provided night time dose of clonapin. She typically takes klonapin 0.5mg TID plus 1mg QHS, but patient reported that she takes more than this at home. On POD#2, she no longer showed signs of withdrawal. #Acute post operative blood loss anemia, Hct 23.0, POD#3, patient is asymptomatic with normal vital signs. PLEASE DO NOT PERFORM LABS UNLESS PATIENT BECOMES SYMPTOMATIC!!!! PLEASE CALL THE ORTHOPAEDIC SURGERY DEPARTMENT PRIOR TO INIATING WORK UP OR SENDING TO THE EMERGENCY DEPARTMENT!!!! Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The surgical dressing was changed and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 crutches at all times for 6 weeks. Ms. [MASKED] is discharged to rehab in stable condition. Medications on Admission: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. ClonazePAM 0.5 mg PO TID:PRN anxiety 4. DULoxetine 60 mg PO DAILY 5. Hydroxychloroquine Sulfate 300 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 5. Senna 8.6 mg PO BID 6. ClonazePAM 1 mg PO QHS 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 8. BuPROPion XL (Once Daily) 300 mg PO DAILY 9. ClonazePAM 0.5 mg PO TID:PRN anxiety 10. DULoxetine 60 mg PO DAILY 11. Hydroxychloroquine Sulfate 300 mg PO DAILY 12. Lisinopril 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, please hold this medication until you have completed your one-month course of anticoagulation medication or unless cleared by your physician. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at follow-up appointment approximately two 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 at all times for 6 weeks. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Assistive device x 6 weeks post-op (i.e., 2 crutches, walker) Mobilize frequently Treatments Frequency: DSD daily prn drainage Ice and elevate *Staples will be removed at your first post-operative visit* Followup Instructions: [MASKED]
[]
[ "D62", "F329", "F419", "E785" ]
[ "M1712: Unilateral primary osteoarthritis, left knee", "D62: Acute posthemorrhagic anemia", "E6601: Morbid (severe) obesity due to excess calories", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "F1290: Cannabis use, unspecified, uncomplicated" ]
10,052,597
23,585,224
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: sulfa drugs Attending: ___ Chief Complaint: right knee pain Major Surgical or Invasive Procedure: Right total knee arthroplasty History of Present Illness: ___ year old female with right knee pain presents for joint replacement. Past Medical History: seizures as an infant, depression/anxiety, HLD, obesity Social History: ___ Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 12:50PM BLOOD WBC-8.9 RBC-2.92* Hgb-8.8* Hct-27.2* MCV-93 MCH-30.1 MCHC-32.4 RDW-13.6 RDWSD-46.5* Plt ___ ___ 08:10AM BLOOD WBC-8.4 RBC-2.70* Hgb-8.1* Hct-25.3* MCV-94 MCH-30.0 MCHC-32.0 RDW-13.9 RDWSD-47.0* Plt ___ ___ 06:30AM BLOOD WBC-11.4* RBC-2.94* Hgb-8.9* Hct-27.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.7 RDWSD-46.9* Plt ___ ___ 10:50AM BLOOD WBC-9.3 RBC-2.97* Hgb-9.0* Hct-27.7* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.8 RDWSD-46.7* Plt ___ ___ 10:50AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 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. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 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. Acetaminophen w/Codeine 1 TAB PO BID:PRN Pain - Moderate 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. ClonazePAM 0.5 mg PO TID 4. DULoxetine 120 mg PO DAILY 5. Hydroxychloroquine Sulfate 300 mg PO DAILY 6. Omeprazole 20 mg PO DAILY:PRN acid reflux 7. Pravastatin 40 mg PO QPM 8. PredniSONE 5 mg PO DAILY 9. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 30 mg SC Q12H Start: ___, First Dose: First Routine Administration Time 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 4. Senna 8.6 mg PO BID 5. Acetaminophen 1000 mg PO Q8H 6. BuPROPion XL (Once Daily) 300 mg PO DAILY 7. ClonazePAM 0.5 mg PO TID 8. DULoxetine 120 mg PO DAILY 9. Omeprazole 20 mg PO DAILY:PRN acid reflux 10. Pravastatin 40 mg PO QPM 11. HELD- Hydroxychloroquine Sulfate 300 mg PO DAILY This medication was held. Do not restart Hydroxychloroquine Sulfate until four weeks postop 12. HELD- PredniSONE 5 mg PO DAILY This medication was held. Do not restart PredniSONE until four weeks postop Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Osteoarthritis right knee Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Expected length of stay in rehab less than 30 days Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking anticoagulation medication. ___ STOCKINGS x 6 WEEKS. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at follow-up appointment approximately two weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing and range of motion as tolerated in right lower extremity, on two crutches or a walker at all times Treatments Frequency: - Dressing changes as needed - Wound checks - Physical therapy - Lovenox teaching - Staples to be removed at first ___ clinic visit Followup Instructions: ___
[ "M1711", "Z6841", "I10", "E6601", "E785", "J45909", "R5082", "F1290" ]
Allergies: sulfa drugs Chief Complaint: right knee pain Major Surgical or Invasive Procedure: Right total knee arthroplasty History of Present Illness: [MASKED] year old female with right knee pain presents for joint replacement. Past Medical History: seizures as an infant, depression/anxiety, HLD, obesity Social History: [MASKED] Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 12:50PM BLOOD WBC-8.9 RBC-2.92* Hgb-8.8* Hct-27.2* MCV-93 MCH-30.1 MCHC-32.4 RDW-13.6 RDWSD-46.5* Plt [MASKED] [MASKED] 08:10AM BLOOD WBC-8.4 RBC-2.70* Hgb-8.1* Hct-25.3* MCV-94 MCH-30.0 MCHC-32.0 RDW-13.9 RDWSD-47.0* Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-11.4* RBC-2.94* Hgb-8.9* Hct-27.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.7 RDWSD-46.9* Plt [MASKED] [MASKED] 10:50AM BLOOD WBC-9.3 RBC-2.97* Hgb-9.0* Hct-27.7* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.8 RDWSD-46.7* Plt [MASKED] [MASKED] 10:50AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 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. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 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. Acetaminophen w/Codeine 1 TAB PO BID:PRN Pain - Moderate 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. ClonazePAM 0.5 mg PO TID 4. DULoxetine 120 mg PO DAILY 5. Hydroxychloroquine Sulfate 300 mg PO DAILY 6. Omeprazole 20 mg PO DAILY:PRN acid reflux 7. Pravastatin 40 mg PO QPM 8. PredniSONE 5 mg PO DAILY 9. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 30 mg SC Q12H Start: [MASKED], First Dose: First Routine Administration Time 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 4. Senna 8.6 mg PO BID 5. Acetaminophen 1000 mg PO Q8H 6. BuPROPion XL (Once Daily) 300 mg PO DAILY 7. ClonazePAM 0.5 mg PO TID 8. DULoxetine 120 mg PO DAILY 9. Omeprazole 20 mg PO DAILY:PRN acid reflux 10. Pravastatin 40 mg PO QPM 11. HELD- Hydroxychloroquine Sulfate 300 mg PO DAILY This medication was held. Do not restart Hydroxychloroquine Sulfate until four weeks postop 12. HELD- PredniSONE 5 mg PO DAILY This medication was held. Do not restart PredniSONE until four weeks postop Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Osteoarthritis right knee Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Expected length of stay in rehab less than 30 days Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking anticoagulation medication. [MASKED] STOCKINGS x 6 WEEKS. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at follow-up appointment approximately two weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing and range of motion as tolerated in right lower extremity, on two crutches or a walker at all times Treatments Frequency: - Dressing changes as needed - Wound checks - Physical therapy - Lovenox teaching - Staples to be removed at first [MASKED] clinic visit Followup Instructions: [MASKED]
[]
[ "I10", "E785", "J45909" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "E6601: Morbid (severe) obesity due to excess calories", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "R5082: Postprocedural fever", "F1290: Cannabis use, unspecified, uncomplicated" ]
10,052,745
20,739,598
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: right knee OA Major Surgical or Invasive Procedure: right total knee replacement ___, ___ History of Present Illness: ___ year old female with right knee OA, failed conservative measures, presenting for right TKA. Past Medical History: HLD, HTN, hypothyroidism 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: ___ 07:58AM BLOOD Hgb-8.0* Hct-25.5* ___ 07:05AM BLOOD Hgb-8.3* Hct-26.5* ___ 07:05AM BLOOD Hgb-8.2* Hct-26.0* ___ 01:08PM BLOOD Creat-1.0 ___ 07:05AM BLOOD Creat-1.0 ___ 07:05AM BLOOD Creat-1.2* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#0, the patient was bladder scanned for 560 mL and had to be straight catheterized in the PACU. She also received two doses of neo in PACU along with 500 mL bolus of fluid for low blood pressure. Her blood pressure stabilized post-interventions. POD#1, the patient's creatinine was 1.2. Her Toradol was discontinued and both her HCTZ and Lisinopril were held. Her Oxycodone was switched to Tramadol due to complaints of dizziness and nausea. POD#2, drain was discontinued. Creatinine was rechecked and was 1.0. POD#3, creatinine was stable at 1.0. Patient to resume Lisinopril-HCTZ upon discharge. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Ms. ___ is discharged to home in stable condition. No home ___ benefits. Patient will begin outpatient physical therapy starting on ___ at 2pm. Medications on Admission: 1. Lisinopril 20 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin EC 81 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 81 mg twice daily. 6. Senna 8.6 mg PO BID 7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate 8. Atorvastatin 40 mg PO QPM 9. Hydrochlorothiazide 25 mg PO DAILY 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___
[ "M1711", "I10", "E785", "E039", "E669", "Z6835" ]
Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: right knee OA Major Surgical or Invasive Procedure: right total knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with right knee OA, failed conservative measures, presenting for right TKA. Past Medical History: HLD, HTN, hypothyroidism 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] 07:58AM BLOOD Hgb-8.0* Hct-25.5* [MASKED] 07:05AM BLOOD Hgb-8.3* Hct-26.5* [MASKED] 07:05AM BLOOD Hgb-8.2* Hct-26.0* [MASKED] 01:08PM BLOOD Creat-1.0 [MASKED] 07:05AM BLOOD Creat-1.0 [MASKED] 07:05AM BLOOD Creat-1.2* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#0, the patient was bladder scanned for 560 mL and had to be straight catheterized in the PACU. She also received two doses of neo in PACU along with 500 mL bolus of fluid for low blood pressure. Her blood pressure stabilized post-interventions. POD#1, the patient's creatinine was 1.2. Her Toradol was discontinued and both her HCTZ and Lisinopril were held. Her Oxycodone was switched to Tramadol due to complaints of dizziness and nausea. POD#2, drain was discontinued. Creatinine was rechecked and was 1.0. POD#3, creatinine was stable at 1.0. Patient to resume Lisinopril-HCTZ upon discharge. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Ms. [MASKED] is discharged to home in stable condition. No home [MASKED] benefits. Patient will begin outpatient physical therapy starting on [MASKED] at 2pm. Medications on Admission: 1. Lisinopril 20 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin EC 81 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 81 mg twice daily. 6. Senna 8.6 mg PO BID 7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate 8. Atorvastatin 40 mg PO QPM 9. Hydrochlorothiazide 25 mg PO DAILY 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices ([MASKED]) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED]
[]
[ "I10", "E785", "E039", "E669" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]
10,052,875
28,599,142
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hay fever / oxycodone Attending: ___. Chief Complaint: fall, fever Major Surgical or Invasive Procedure: Flex sig ___ History of Present Illness: ___ history of HTN, recently diagnosed anal fistulas who initially presented to an OSH after falling at the golf course in the setting of fevers to 102.7 and a month of LLQ abdominal pain. The patient also reports associated intermittent diarrhea, non-bloody. Denies po intolerance or dysuria. Denies prior episodes of similar pain. At the OSH, she underwent CT imaging initially read as concerning for microperforated colitis or diverticulitis, prompting her transfer here. Repeat CT imaging was obtained here due to inability to transfer the imaging from the OSH. Of note, the patient was seen by Dr. ___ in clinic on ___ due to her PCP's concern for perianal disease. She was noted to have a perianal fistula on exam and underwent an MRI pelvis on ___ showing multiple complex anal fistulas; no further work-up or intervention has been performed. Her last colonoscopy was in ___ without concern for IBD and no evidence of diverticulosis; 4 sessile polyps were removed with hyperplastic pathology. Past Medical History: PMH: complex fistula-in-ano HTN PSH: vein stripping (b/l)- ___ excision R breast papillomatosis- ___ Social History: ___ Family History: Denies FH of IBD. Father with colon cancer at age ___. Mother with colon cancer in ___. Physical Exam: ADMISSION EXAM: ========== Vitals-98.00 81 122/71 22 95RA General- no acute distress HEENT- face flushed, PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB Abdomen- soft, moderately tender to palpation in the suprapubic region and LLQ with involuntary guarding, nondistended. No rebound. Rectal exam without palpable mass or gross blood, posterior midline fistula tract noted with scant purulent drainage. Ext- WWP, no edema DISCHARGE EXAM: ========== VS: ___ 1126 Temp: 98.5 PO BP: 116/71 L Lying HR: 86 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. No carotid bruit 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 GU catheter in place MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: abrasion in R temporal area and R shoulder PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ============= ___ 09:38PM BLOOD WBC-9.9 RBC-3.36* Hgb-7.6* Hct-26.7* MCV-80* MCH-22.6* MCHC-28.5* RDW-16.4* RDWSD-46.8* Plt ___ ___ 09:38PM BLOOD Neuts-79.9* Lymphs-9.4* Monos-9.7 Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.92* AbsLymp-0.93* AbsMono-0.96* AbsEos-0.01* AbsBaso-0.02 ___ 09:38PM BLOOD ___ PTT-26.4 ___ ___ 09:38PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138 K-4.1 Cl-99 HCO3-25 AnGap-14 ___ 09:38PM BLOOD ALT-12 AST-17 AlkPhos-63 TotBili-0.2 ___ 09:38PM BLOOD Lipase-13 ___ 09:38PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-2.0 ___ 09:38PM BLOOD CRP-89.8* ___ 09:44PM BLOOD Lactate-0.8 IMPORTANT INTERIM RESULTS: ============= ___ 05:13AM BLOOD calTIBC-170* Ferritn-726* TRF-131* ___ 05:00AM BLOOD Triglyc-168* ___ 05:13AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG MICRO: ============= ___ 8:07 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ Blood Culture x1 - NEGATIVE ___ C Diff PCR - NEGATIVE ___ O/P - NEGATIVE ___ O/P - NEGATIVE ___ MRSA SCREEN - NEGATIVE IMAGING: ============= ___ CT ABD/PEL W/ CO 1. Extensive inflammatory change and adjacent phlegmon involving the sigmoid colon greater than the rectum. These findings are consistent with a severe proctocolitis, and Crohn's disease is favored given the presence of a perianal fistula and appearance of penetrating disease. An infectious etiology could also be considered. The appearance and distribution are less compatible with ischemia. 2. No fluid collection. No evidence of perforation. No intrapelvic fistula. 3. Known perianal fistula is better seen on the recent MRI performed ___. ___ CT ABD/PEL W/ CO 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. RECOMMENDATION(S): For pancreatic cysts measuring more than 1.5cm, patients should be referred to the pancreas cyst clinic for consultation. These referrals can be made by emailing ___ or by calling ___. For cysts measuring up to 1.5 cm: (a) These guidelines apply only to incidental findings, and not to patients who are symptomatic, have abnormal blood tests, or have history of pancreas neoplasm resection. (b) Clinical decisions should be made on a case-by-case basis taking into account patient's comorbidities, family history, willingness to undergo treatment, and risk tolerance. Local ___ follow-up guidelines adopted from: ___ ___ TTE Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. DISCHARGE LABS: ============= ___ 05:03AM BLOOD WBC-7.3 RBC-3.25* Hgb-7.4* Hct-26.0* MCV-80* MCH-22.8* MCHC-28.5* RDW-17.5* RDWSD-49.4* Plt ___ ___ 05:03AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-4.2 Cl-105 HCO3-24 AnGap-12 ___ 05:03AM BLOOD CRP-13.1* Brief Hospital Course: Ms. ___ presented to ___ on ___, arriving from an OSH, after having a fall (syncope) at a golf course, fevers of 102.7F, 1 month LLQ abd pain, with nonbloody diarrhea intermittently. She was transferred from the OSH to surgical service after being found on CT to have a possible microperforated colitis/diverticulitis. SURGERY HOSPITAL COURSE: She was seen colorectal surgeon Dr. ___ had an MRI in ___ showing multiple complex anal fistulas. Upon admission, pt was admitted to the colorectal surgery service treated with Zosyn, made NPO w IVFs, received serial abdominal exams, had her CRP trended, stool studies (Cdiff, O&P - r/o infectious colitis), with a GI and medicine consult. CV: Medicine was consulted for a syncope work up and had EKGs, TTE, as well as telemetry performed. EKGs - showed NSR with PACs TTE - IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. Telemetry - no arrhythmias reported. Syncope work up was not pursued further inpatient with a stress test recommended outpatient. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. She had good pulmonary toileting, as early ambulation were encouraged throughout hospitalization. GI: Pt initially received a repeat CT abd/pelvis with contrast because of inability to obtain OSH records. CT abd/pelvis w contrast showed - IMPRESSION: 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to ___/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Pt was made NPO w IVF and had a PICC placed with Nutrition recommending initiation of TPN. GI was consulted and recommended infectious colitis work up (O&P, c.diff), hepatitis serologies, a quant gold, clear liquid diet attempt, abx, planned scope, CRP trending. GI also recommended a repeat CT in 2 weeks to ensure improvement with long term management including a full colonoscopy (luminal and TI eval w dx biopsies - prior to antiTNF initiation). She received a flexible sigmoidoscopy during her stay which showed: Erosions, friability and severe inflammation of the rectum and sigmoid though with preferential involvement of the rectum. Biopsies taken. In combination with anal fistulae, as discussed before, this most likely represents new diagnosis of Crohn's disease. GU: UA and urine cultures were negative. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: Pt was tested for C.diff, HBV serologies, TB quantiferon gold (pre-biologic rx initiation testing), blood and urine cxs, MRSA. MRSA, HBV, blood and urine cx's, cdiff were negative. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to cipro/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Heme: The patient received subcutaneous heparin and ___ dyne boots during this stay. She was encouraged to get up and ambulate as early as possible. MEDICINE HOSPITAL COURSE: Patient was transferred to medical team on ___ given ongoing need for inpatient monitoring on antibiotics for treatment of intra-abdominal infection. Antibiotics continued with ciprofloxacin and flagyl. On ___, CRP down to 13 and patient feeling significantly better. After discussion with GI team, patient stable for discharge. Plan to continue these antibiotics on discharge, with final course to be determined by GI after follow-up arranged in Dr. ___. GI will arrange repeat imaging at that time. In regards to syncope, patient did not seem to actually syncopize, rather fell over and hit her head on the ground with minor abrasions. EKG with nonspecific T wave changes and TTE with mild hypokinesis in distribution of single vessel. Very low suspicion for acute coronary event. Patient will follow up with PCP for outpatient stress test. TRANSITIONAL ISSUES: [] Outpatient stress test scheduled by PCP to evaluate changes on TTE [] GI follow-up will be arranged by their clinic and patient will be contacted [] QUANT-GOLD pending on discharge (drew on ___ but issue with tubes, so re-drawn on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. raloxifene 60 mg oral DAILY 2. Rosuvastatin Calcium 20 mg PO QPM 3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Take until your GI follow-up, final course to be determined by repeat imaging. RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID Take until your GI follow-up, final course to be determined by repeat imaging. RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*63 Tablet Refills:*0 3. raloxifene 60 mg oral DAILY 4. Rosuvastatin Calcium 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Inflammatory bowel disease/Crohn's Disease Fistula with abscess Fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___, You were admitted to the hospital for fever, fall, and found to have GI fistula with infection. You were started on antibiotics and seen by GI, who performed a flexible sigmoidoscopy which showed inflammation in your colon consistent with likely new diagnosis of Crohn's Disease. You will continue antibiotics, and will need to follow-up closely with GI after discharge to determine the further course of action and have discussions about treating the Crohn's. It was a pleasure taking care of you! Sincerely, your ___ Team Followup Instructions: ___
[ "K50914", "K50913", "I10" ]
Allergies: hay fever / oxycodone Chief Complaint: fall, fever Major Surgical or Invasive Procedure: Flex sig [MASKED] History of Present Illness: [MASKED] history of HTN, recently diagnosed anal fistulas who initially presented to an OSH after falling at the golf course in the setting of fevers to 102.7 and a month of LLQ abdominal pain. The patient also reports associated intermittent diarrhea, non-bloody. Denies po intolerance or dysuria. Denies prior episodes of similar pain. At the OSH, she underwent CT imaging initially read as concerning for microperforated colitis or diverticulitis, prompting her transfer here. Repeat CT imaging was obtained here due to inability to transfer the imaging from the OSH. Of note, the patient was seen by Dr. [MASKED] in clinic on [MASKED] due to her PCP's concern for perianal disease. She was noted to have a perianal fistula on exam and underwent an MRI pelvis on [MASKED] showing multiple complex anal fistulas; no further work-up or intervention has been performed. Her last colonoscopy was in [MASKED] without concern for IBD and no evidence of diverticulosis; 4 sessile polyps were removed with hyperplastic pathology. Past Medical History: PMH: complex fistula-in-ano HTN PSH: vein stripping (b/l)- [MASKED] excision R breast papillomatosis- [MASKED] Social History: [MASKED] Family History: Denies FH of IBD. Father with colon cancer at age [MASKED]. Mother with colon cancer in [MASKED]. Physical Exam: ADMISSION EXAM: ========== Vitals-98.00 81 122/71 22 95RA General- no acute distress HEENT- face flushed, PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB Abdomen- soft, moderately tender to palpation in the suprapubic region and LLQ with involuntary guarding, nondistended. No rebound. Rectal exam without palpable mass or gross blood, posterior midline fistula tract noted with scant purulent drainage. Ext- WWP, no edema DISCHARGE EXAM: ========== VS: [MASKED] 1126 Temp: 98.5 PO BP: 116/71 L Lying HR: 86 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. No carotid bruit 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 GU catheter in place MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: abrasion in R temporal area and R shoulder PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ============= [MASKED] 09:38PM BLOOD WBC-9.9 RBC-3.36* Hgb-7.6* Hct-26.7* MCV-80* MCH-22.6* MCHC-28.5* RDW-16.4* RDWSD-46.8* Plt [MASKED] [MASKED] 09:38PM BLOOD Neuts-79.9* Lymphs-9.4* Monos-9.7 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-7.92* AbsLymp-0.93* AbsMono-0.96* AbsEos-0.01* AbsBaso-0.02 [MASKED] 09:38PM BLOOD [MASKED] PTT-26.4 [MASKED] [MASKED] 09:38PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138 K-4.1 Cl-99 HCO3-25 AnGap-14 [MASKED] 09:38PM BLOOD ALT-12 AST-17 AlkPhos-63 TotBili-0.2 [MASKED] 09:38PM BLOOD Lipase-13 [MASKED] 09:38PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-2.0 [MASKED] 09:38PM BLOOD CRP-89.8* [MASKED] 09:44PM BLOOD Lactate-0.8 IMPORTANT INTERIM RESULTS: ============= [MASKED] 05:13AM BLOOD calTIBC-170* Ferritn-726* TRF-131* [MASKED] 05:00AM BLOOD Triglyc-168* [MASKED] 05:13AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG MICRO: ============= [MASKED] 8:07 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] Blood Culture x1 - NEGATIVE [MASKED] C Diff PCR - NEGATIVE [MASKED] O/P - NEGATIVE [MASKED] O/P - NEGATIVE [MASKED] MRSA SCREEN - NEGATIVE IMAGING: ============= [MASKED] CT ABD/PEL W/ CO 1. Extensive inflammatory change and adjacent phlegmon involving the sigmoid colon greater than the rectum. These findings are consistent with a severe proctocolitis, and Crohn's disease is favored given the presence of a perianal fistula and appearance of penetrating disease. An infectious etiology could also be considered. The appearance and distribution are less compatible with ischemia. 2. No fluid collection. No evidence of perforation. No intrapelvic fistula. 3. Known perianal fistula is better seen on the recent MRI performed [MASKED]. [MASKED] CT ABD/PEL W/ CO 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. RECOMMENDATION(S): For pancreatic cysts measuring more than 1.5cm, patients should be referred to the pancreas cyst clinic for consultation. These referrals can be made by emailing [MASKED] or by calling [MASKED]. For cysts measuring up to 1.5 cm: (a) These guidelines apply only to incidental findings, and not to patients who are symptomatic, have abnormal blood tests, or have history of pancreas neoplasm resection. (b) Clinical decisions should be made on a case-by-case basis taking into account patient's comorbidities, family history, willingness to undergo treatment, and risk tolerance. Local [MASKED] follow-up guidelines adopted from: [MASKED] [MASKED] TTE Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. DISCHARGE LABS: ============= [MASKED] 05:03AM BLOOD WBC-7.3 RBC-3.25* Hgb-7.4* Hct-26.0* MCV-80* MCH-22.8* MCHC-28.5* RDW-17.5* RDWSD-49.4* Plt [MASKED] [MASKED] 05:03AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-4.2 Cl-105 HCO3-24 AnGap-12 [MASKED] 05:03AM BLOOD CRP-13.1* Brief Hospital Course: Ms. [MASKED] presented to [MASKED] on [MASKED], arriving from an OSH, after having a fall (syncope) at a golf course, fevers of 102.7F, 1 month LLQ abd pain, with nonbloody diarrhea intermittently. She was transferred from the OSH to surgical service after being found on CT to have a possible microperforated colitis/diverticulitis. SURGERY HOSPITAL COURSE: She was seen colorectal surgeon Dr. [MASKED] had an MRI in [MASKED] showing multiple complex anal fistulas. Upon admission, pt was admitted to the colorectal surgery service treated with Zosyn, made NPO w IVFs, received serial abdominal exams, had her CRP trended, stool studies (Cdiff, O&P - r/o infectious colitis), with a GI and medicine consult. CV: Medicine was consulted for a syncope work up and had EKGs, TTE, as well as telemetry performed. EKGs - showed NSR with PACs TTE - IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. Telemetry - no arrhythmias reported. Syncope work up was not pursued further inpatient with a stress test recommended outpatient. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. She had good pulmonary toileting, as early ambulation were encouraged throughout hospitalization. GI: Pt initially received a repeat CT abd/pelvis with contrast because of inability to obtain OSH records. CT abd/pelvis w contrast showed - IMPRESSION: 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to [MASKED]/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Pt was made NPO w IVF and had a PICC placed with Nutrition recommending initiation of TPN. GI was consulted and recommended infectious colitis work up (O&P, c.diff), hepatitis serologies, a quant gold, clear liquid diet attempt, abx, planned scope, CRP trending. GI also recommended a repeat CT in 2 weeks to ensure improvement with long term management including a full colonoscopy (luminal and TI eval w dx biopsies - prior to antiTNF initiation). She received a flexible sigmoidoscopy during her stay which showed: Erosions, friability and severe inflammation of the rectum and sigmoid though with preferential involvement of the rectum. Biopsies taken. In combination with anal fistulae, as discussed before, this most likely represents new diagnosis of Crohn's disease. GU: UA and urine cultures were negative. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: Pt was tested for C.diff, HBV serologies, TB quantiferon gold (pre-biologic rx initiation testing), blood and urine cxs, MRSA. MRSA, HBV, blood and urine cx's, cdiff were negative. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to cipro/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Heme: The patient received subcutaneous heparin and [MASKED] dyne boots during this stay. She was encouraged to get up and ambulate as early as possible. MEDICINE HOSPITAL COURSE: Patient was transferred to medical team on [MASKED] given ongoing need for inpatient monitoring on antibiotics for treatment of intra-abdominal infection. Antibiotics continued with ciprofloxacin and flagyl. On [MASKED], CRP down to 13 and patient feeling significantly better. After discussion with GI team, patient stable for discharge. Plan to continue these antibiotics on discharge, with final course to be determined by GI after follow-up arranged in Dr. [MASKED]. GI will arrange repeat imaging at that time. In regards to syncope, patient did not seem to actually syncopize, rather fell over and hit her head on the ground with minor abrasions. EKG with nonspecific T wave changes and TTE with mild hypokinesis in distribution of single vessel. Very low suspicion for acute coronary event. Patient will follow up with PCP for outpatient stress test. TRANSITIONAL ISSUES: [] Outpatient stress test scheduled by PCP to evaluate changes on TTE [] GI follow-up will be arranged by their clinic and patient will be contacted [] QUANT-GOLD pending on discharge (drew on [MASKED] but issue with tubes, so re-drawn on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. raloxifene 60 mg oral DAILY 2. Rosuvastatin Calcium 20 mg PO QPM 3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Take until your GI follow-up, final course to be determined by repeat imaging. RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID Take until your GI follow-up, final course to be determined by repeat imaging. RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*63 Tablet Refills:*0 3. raloxifene 60 mg oral DAILY 4. Rosuvastatin Calcium 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Inflammatory bowel disease/Crohn's Disease Fistula with abscess Fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED], You were admitted to the hospital for fever, fall, and found to have GI fistula with infection. You were started on antibiotics and seen by GI, who performed a flexible sigmoidoscopy which showed inflammation in your colon consistent with likely new diagnosis of Crohn's Disease. You will continue antibiotics, and will need to follow-up closely with GI after discharge to determine the further course of action and have discussions about treating the Crohn's. It was a pleasure taking care of you! Sincerely, your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10" ]
[ "K50914: Crohn's disease, unspecified, with abscess", "K50913: Crohn's disease, unspecified, with fistula", "I10: Essential (primary) hypertension" ]
10,052,926
29,714,792
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / vancomycin / Cephalosporins / Lyrica / Pyridium Attending: ___. Chief Complaint: symptomatic cholelithiasis Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy History of Present Illness: Mr. ___ is a ___ w/history of prostate cancer, GERD c/b ___, thoracic AA, HTN who presents with epigastric abdominal pain in the setting of known gallstones. ACS is consulted for evaluation and management of symptomatic cholelithiasis. Pt reports his pain began suddenly at midnight on the day of presentation. Pain is described as sharp, constant, localized to the epigastrum w/occasional RUQ pain and no radiation. He also complains of ___ episodes of nonbloody emesis and ___ nonbloody loose stools this AM. He has not tolerated PO today. Denies fever, chills. No sick contacts or new food exposures. Of note, pt had a similar episode of epigastric pain prompting ED evaluation on ___ with RUQ U/S showing gallstones without evidence of cholecystitis. Past Medical History: PROSTATE CANCER: detected by elevated PSA, ___ 3+3, on active surveillance with routine biopsies ASCENDING THORACIC AORTIC ANEURYSM DEPRESSION HYPERTENSION LOW BACK PAIN OBSTRUCTIVE SLEEP APNEA PRE-DIABETES RIGHT OPEN TIBIAL FRACTURE ASTEATOTIC ECZEMA LATENT TB (never treated) POSTERIOR VITREOUS DETACHMENT OD CATARACTS ___ ESOPHAGUS INGUINAL HERNIA H/O CLOSTRIDIUM DIFFICILE Social History: ___ Family History: Father died of prostate cancer at ___, had CAD s/p CABG and ESRD. Mother with hypertension. Physical Exam: Gen: Awake and alert CV: RRR Resp: CTAB Abd: Soft, appropriately tender, nondistended Incisions: Clean, dry, dressings intact, mild serasanguinous staining on epigastric port site Extremities: WWP Pertinent Results: ___ 12:05 142 ___ AGap=18 3.6 27 0.6 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Ca: 9.1 Mg: 2.0 P: 3.0 ALT: 35 AP: 82 Tbili: 0.9 Alb: 4.2 AST: 27 LDH: Dbili: TProt: ___: Lip: 50 87 5.5 ___ 15.3 230 46.5 N:58.7 L:28.7 M:9.1 E:2.2 Bas:0.9 ___: 0.4 Absneut: 3.23 ___ Abslymp: 1.58 Absmono: 0.50 Abseos: 0.12 Absbaso: 0.05 ___: 10.4 PTT: 39.2 INR: 1.0 Brief Hospital Course: Mr. ___ was admitted on ___ under the acute care surgery service for management of her acute cholecystitis. He was taken to the operating room and underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of POD #1 to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was unable to void post-operatively, and a Foley catheter was placed. After multiple failed attempts, urology was consulted to place the Foley catheter. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On POD #1, he was discharged home with a foley catheter in place. He will follow up in ___ clinic and with his home urologist for foley removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Gabapentin 400 mg PO TID 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Acetaminophen 1000 mg PO Q8H:PRN pain 7. Docusate Sodium 100 mg PO TID:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amiloride HCl 10 mg PO DAILY 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Docusate Sodium 100 mg PO TID:PRN constipation 5. Finasteride 5 mg PO DAILY 6. Gabapentin 400 mg PO TID 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Sertraline 200 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50-100 mg PO QHS:PRN sleep 12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 13. Aspirin 81 mg PO DAILY 14. Chlorthalidone 25 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Symptomatic cholelithiasis 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 symptomatic gallstones. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. FOLEY CATHETER: You had difficulty urinating after your surgery. A Foley catheter had to be placed in your bladder to help with this. It was difficulty to put in, and it will stay in for one week. You will follow-up with urology and they will tell you when to remove this. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
[ "K8000", "I712", "Z8546", "K2270", "K219", "I10", "G4733", "F329", "R7611", "F419", "H269", "Z8042", "Z7982", "G8918", "R339" ]
Allergies: Penicillins / vancomycin / Cephalosporins / Lyrica / Pyridium Chief Complaint: symptomatic cholelithiasis Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy History of Present Illness: Mr. [MASKED] is a [MASKED] w/history of prostate cancer, GERD c/b [MASKED], thoracic AA, HTN who presents with epigastric abdominal pain in the setting of known gallstones. ACS is consulted for evaluation and management of symptomatic cholelithiasis. Pt reports his pain began suddenly at midnight on the day of presentation. Pain is described as sharp, constant, localized to the epigastrum w/occasional RUQ pain and no radiation. He also complains of [MASKED] episodes of nonbloody emesis and [MASKED] nonbloody loose stools this AM. He has not tolerated PO today. Denies fever, chills. No sick contacts or new food exposures. Of note, pt had a similar episode of epigastric pain prompting ED evaluation on [MASKED] with RUQ U/S showing gallstones without evidence of cholecystitis. Past Medical History: PROSTATE CANCER: detected by elevated PSA, [MASKED] 3+3, on active surveillance with routine biopsies ASCENDING THORACIC AORTIC ANEURYSM DEPRESSION HYPERTENSION LOW BACK PAIN OBSTRUCTIVE SLEEP APNEA PRE-DIABETES RIGHT OPEN TIBIAL FRACTURE ASTEATOTIC ECZEMA LATENT TB (never treated) POSTERIOR VITREOUS DETACHMENT OD CATARACTS [MASKED] ESOPHAGUS INGUINAL HERNIA H/O CLOSTRIDIUM DIFFICILE Social History: [MASKED] Family History: Father died of prostate cancer at [MASKED], had CAD s/p CABG and ESRD. Mother with hypertension. Physical Exam: Gen: Awake and alert CV: RRR Resp: CTAB Abd: Soft, appropriately tender, nondistended Incisions: Clean, dry, dressings intact, mild serasanguinous staining on epigastric port site Extremities: WWP Pertinent Results: [MASKED] 12:05 142 [MASKED] AGap=18 3.6 27 0.6 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Ca: 9.1 Mg: 2.0 P: 3.0 ALT: 35 AP: 82 Tbili: 0.9 Alb: 4.2 AST: 27 LDH: Dbili: TProt: [MASKED]: Lip: 50 87 5.5 [MASKED] 15.3 230 46.5 N:58.7 L:28.7 M:9.1 E:2.2 Bas:0.9 [MASKED]: 0.4 Absneut: 3.23 [MASKED] Abslymp: 1.58 Absmono: 0.50 Abseos: 0.12 Absbaso: 0.05 [MASKED]: 10.4 PTT: 39.2 INR: 1.0 Brief Hospital Course: Mr. [MASKED] was admitted on [MASKED] under the acute care surgery service for management of her acute cholecystitis. He was taken to the operating room and underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of POD #1 to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was unable to void post-operatively, and a Foley catheter was placed. After multiple failed attempts, urology was consulted to place the Foley catheter. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On POD #1, he was discharged home with a foley catheter in place. He will follow up in [MASKED] clinic and with his home urologist for foley removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Gabapentin 400 mg PO TID 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Acetaminophen 1000 mg PO Q8H:PRN pain 7. Docusate Sodium 100 mg PO TID:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amiloride HCl 10 mg PO DAILY 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Docusate Sodium 100 mg PO TID:PRN constipation 5. Finasteride 5 mg PO DAILY 6. Gabapentin 400 mg PO TID 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Sertraline 200 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50-100 mg PO QHS:PRN sleep 12. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 13. Aspirin 81 mg PO DAILY 14. Chlorthalidone 25 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Symptomatic cholelithiasis 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 symptomatic gallstones. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. FOLEY CATHETER: You had difficulty urinating after your surgery. A Foley catheter had to be placed in your bladder to help with this. It was difficulty to put in, and it will stay in for one week. You will follow-up with urology and they will tell you when to remove this. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]
[]
[ "K219", "I10", "G4733", "F329", "F419" ]
[ "K8000: Calculus of gallbladder with acute cholecystitis without obstruction", "I712: Thoracic aortic aneurysm, without rupture", "Z8546: Personal history of malignant neoplasm of prostate", "K2270: Barrett's esophagus without dysplasia", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "F419: Anxiety disorder, unspecified", "H269: Unspecified cataract", "Z8042: Family history of malignant neoplasm of prostate", "Z7982: Long term (current) use of aspirin", "G8918: Other acute postprocedural pain", "R339: Retention of urine, unspecified" ]
10,052,938
24,661,451
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, Biliary Drain Leak Major Surgical or Invasive Procedure: ___: B/L PTBD exchange with upsize of L to ___ F. U/S guided hepatic dome abscess drain placement (___). ___: ___ cholangiogram which showed left sided drain in good position, right sided PTBD upsized to ___ ___: R PICC placement History of Present Illness: ___ with history of COPD on 2L O2, DMII, CHF, and metastatic cholangiocarcinoma s/p PTBD with recent cholangitis who presents with diffuse abdominal pain and drainage from her PTBD site. She reports no symptoms apart from increased drainage from her tube sites. She denied fevers/chills, worsening abdominal pain, lightheadedness, chest pain, shortness of breath. Notably, she was recently admitted with cholangitis complicated by E. coli and Group D strep bacteremia. She had a failed ERCP on ___ as GI was unable to gain access to prioximal biliary tree. She underwent ___ percutaneous biliary drain placement with ___. TTE was obtained given group D strep bacteremia and was negative for vegetations. ID did not feel that TEE was necessary, given known source of infection and rapid clearance of blood cultures. She was initially treated with vanc/cefepime/flagyl, and transitioned to levofloxacin/flagyl at discharge per ID recommendations. She just completed a 2 week course of these antibiotics on ___. Her course was also notable for hypotension with systolics in the ___, which may be her baseline. - In the ED, initial vitals were: T 98.2F HR 90 BP 84/59 RR 20 O2 97% 2L NC - Labs were notable for: WBC 9 Hgb 10.1 Plt 285 BMP overall unremarkable Mg 1.3 Alk phos 162 Lipase 248, other LFTs unremarkable Lactate 2.5 -> 1.6 UA with 18 leukocytes INR 1.5 - Studies were notable for: CXR Relatively rounded 2.6 cm locule of air in the right upper quadrant for which cross-sectional imaging is suggested. CT abdomen and pelvis with contrast 1. Biliary stent extending into the small bowel with interval placement of two percutaneous catheters, one traveling within and one traveling adjacent to the stent into the small bowel. 2. Multiple predominantly air filled collections within the right lobe of the liver worrisome for abscesses, new since ___. 3. Findings compatible with patient's metastatic cholangiocarcinoma with conglomerate soft tissue mass at the porta hepatis involving the duodenum and pancreatic head with adjacent adenopathy and severe narrowing of the main portal vein. Metastatic lesions in the liver which have slightly enlarged since prior. 4. Indeterminate right adrenal nodule, potentially metastatic. 5. Large stool burden throughout the colon. - The patient was given: 1.5 L IV LR IV Piperacillin-Tazobactam 4.5 g - ___ were consulted: "Bilious leakage from insertion site of left PTBD. I attached to drainage bag for decompression. Will exchange." On arrival to the floor, she says she has no pain. The only thing bothering her is the discharge from around the drains. Past Medical History: COPD on 2L Home O2 Type 2 Diabetes Primary Hypertension Cholangiocarcinoma metastatic to liver/lung Right Sided CHF Hyponatremia Social History: ___ Family History: Son: DM Mother: CAD->sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ Temp: 97.7 PO BP: 107/67 HR: 82 RR: 18 O2 sat: 96% O2 delivery: 3L GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. 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: Right and left biliary drains with leakage of yellow bilious liquid from left drain. Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: ========================= 24 HR Data (last updated ___ @ 1211) Temp: 97.7 (Tm 98.9), BP: 94/61 (92-102/61-68), HR: 86 (86-112), RR: 16 (___), O2 sat: 99% (98-100) General: ___ speaking woman in no acute distress Cardiovascular: S1-S2 present, regular rate and rhythm, no murmurs rubs or gallops. Pulmonary: Clear to auscultation bilaterally Abdomen: Soft nontender nondistended. Non tender. minimal drainage on dressings, Biliary drains draining green fluid, JP drain with serosanguinous drainage. Extremities: Warm well perfused, no edema Pertinent Results: ADMISSION LABS: ============== ___ 12:28PM BLOOD WBC-9.0 RBC-3.47* Hgb-10.1* Hct-32.0* MCV-92 MCH-29.1 MCHC-31.6* RDW-16.0* RDWSD-54.5* Plt ___ ___ 12:28PM BLOOD Neuts-82.3* Lymphs-7.2* Monos-7.7 Eos-0.4* Baso-0.6 Im ___ AbsNeut-7.37* AbsLymp-0.64* AbsMono-0.69 AbsEos-0.04 AbsBaso-0.05 ___ 12:28PM BLOOD ___ PTT-35.5 ___ ___ 12:28PM BLOOD Glucose-116* UreaN-8 Creat-0.8 Na-134* K-3.8 Cl-87* HCO3-33* AnGap-14 ___ 12:28PM BLOOD ALT-6 AST-23 AlkPhos-162* TotBili-1.0 ___ 12:28PM BLOOD Lipase-248* ___ 12:28PM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.2* Mg-1.3* ___ 12:39PM BLOOD ___ pO2-32* pCO2-56* pH-7.42 calTCO2-38* Base XS-9 Comment-GREEN TOP ___ 12:39PM BLOOD Lactate-2.5* RELEVANT INTERVAL LABS: ===================== ___ 11:09PM BLOOD WBC-4.8 RBC-2.15* Hgb-6.4* Hct-20.5* MCV-95 MCH-29.8 MCHC-31.2* RDW-18.1* RDWSD-62.2* Plt ___ ___ 04:50PM BLOOD Glucose-444* UreaN-13 Creat-0.5 Na-133* K-4.2 Cl-89* HCO3-30 AnGap-14 ___ 06:03AM BLOOD ALT-7 AST-22 LD(LDH)-212 AlkPhos-212* TotBili-0.7 ___ 05:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.4* ___ 05:07AM BLOOD ___ PTT-34.3 ___ DISCHARGE LABS: ============== ___ 05:28AM BLOOD WBC-6.0 RBC-2.72* Hgb-8.4* Hct-26.6* MCV-98 MCH-30.9 MCHC-31.6* RDW-18.0* RDWSD-63.7* Plt ___ ___ 05:28AM BLOOD Glucose-132* UreaN-18 Creat-0.5 Na-134* K-4.6 Cl-94* HCO3-28 AnGap-12 ___ 05:28AM BLOOD AlkPhos-179* ___ 05:28AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1 ============== MICROBIOLOGY: ============== ___ 5:58 pm ABSCESS Source: liver abscess. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). Reported to and read back by ___ AT 2211 ON ___. FLUID CULTURE (Final ___: IDENTIFICATION AND SUSCEPTIBILITIES ON ALL ORGANISMS ISOLATED PER ___ (___) ___. ESCHERICHIA COLI. SPARSE GROWTH. Ertapenem Susceptibility testing requested per ___ ___ (___) ___. Ertapenem SUSCEPTIBLE test result performed by ___ ___. TETRACYCLINE Susceptibility testing requested per ___ ___ ___ (___) ___. TETRACYCLINE test result performed by ___. ESCHERICHIA COLI. RARE GROWTH. ___ MORPHOLOGY. Ertapenem Susceptibility testing requested per ___ ___ (___) ___. Ertapenem SUSCEPTIBLE test result performed by ___ ___. TETRACYCLINE Susceptibility testing requested per ___ ___ ___ (___) ___. TETRACYCLINE test result performed by ___. ___ ALBICANS. SPARSE GROWTH. Yeast Susceptibility:. Fluconazole MIC OF 0.25 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. MIXED BACTERIAL FLORA. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- =>64 R =>64 R CEFTAZIDIME----------- =>64 R 16 I CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TETRACYCLINE---------- R R TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. =============== REPORTS: =============== ___ CXR: Relatively rounded 2.6 cm locule of air in the right upper quadrant for which cross-sectional imaging is suggested. ___ CT Abdomen/Pelvis w/contrast: 1. Biliary stent extending into the small bowel with interval placement of two percutaneous catheters, one traveling within and one traveling adjacent to the stent into the small bowel. 2. Multiple predominantly air filled collections within the right lobe of the liver worrisome for abscesses, new since ___. 3. Findings compatible with patient's metastatic cholangiocarcinoma with conglomerate soft tissue mass at the porta hepatis involving the duodenum and pancreatic head with adjacent adenopathy and severe narrowing of the main portal vein. Metastatic lesions in the liver which have slightly enlarged since prior. 4. Indeterminate right adrenal nodule, potentially metastatic. 5. Large stool burden throughout the colon. ___ EXCHANGE BILIARY DRG CATH: -Successful exchange of bilateral internal external PTBDs with upsize of the left-sided drain to a 12 ___ drain. Drains left open to gravity bag drainage. -Successful placement of an 8 ___ pigtail drainage catheter into a hepatic dome abscess under ultrasound and fluoroscopic guidance connected to a JP drain. ___ EXCHANGE BILIARY DRG CATH: -Satisfactory positioning of left-sided internal external PTB D -No intrahepatic biliary dilatation. -Bare metal stent in the common bile duct is patent with antegrade flow of contrast from the intrahepatic bile ducts through the stent and into the small bowel. -Filling of non dilated right posterior ducts on right-sided PTB D pull-back cholangiogram. These duct appear to drain centrally near the location of the bare metal stent. -Satisfactory positioning of new right-sided 12 ___ internal external PTB D. ___ CXR: PICC line terminating at the cavoatrial junction. ___ EKG: SR, low voltage limb leads, TWI in lateral leads, QTc ___RIEF HOSPITAL COURSE: ========================= Ms. ___ is a ___ ___ speaking woman with a history of COPD on 2 L home O2,type 2 diabetes, primarily right-sided CHF and metastatic colonic carcinoma status post hepaticoduodenostomy with placement of a bare-metal CBD stent in ___, more recent admission for cholangitis status post right and left PTBD drains who presented with abdominal pain and leakage from the drains and was found to have a liver abscess. She had upsizing of both PTBD drains to prevent further leak, she had a JP drain placed in the liver abscess which grew E. coli multidrug resistance and ___ she was started on meropenem and fluconazole. She had a PICC placement for at least 3 weeks of ertapenem and she will follow-up with infectious disease. We will plan to follow-up with interventional radiology for repeat CT scan 1 week after discharge to consider for removal of the liver abscess JP drain, and then 2 weeks after discharge for consideration of side-by-side stenting of the biliary system. TRANSITIONAL ISSUES: ========================= [ ] Ongoing goals of care discussion. Patient wants to spend as much time home and out of the hospital with her family, ideally to return to ___ if possible [ ] Infectious disease: Right upper quadrant ultrasound the liver first week of ___. [ ] Follow-up in ___ clinic, ___. [ ] Will need to come to ___ for daily infusions of ertapenem 1 g daily IV for at least 3 weeks. Tentative plan for ___ through ___ at infusion clinic and ___ at hematology/oncology. [ ] Continue fluconazole 400 mg daily for at least 3 weeks [ ] Interventional radiology: Follow-up for removal of JP drain following repeat imaging, she will need a repeat CT with contrast of the abdomen and pelvis [ ] Interventional radiology: Follow-up in 2 weeks for potential side-by-side stenting of left biliary system on ___ [ ] consider uptitrating glipizide for better blood sugar control. ACUTE/ACTIVE ISSUES: ========================= #Biliary drain leakage Patient had a recent PTBD drain placement in the setting of cholangitis, however she returned with abdominal pain and some leakage from the drain sites. She had a replacement of the left PTBD drains on ___ and the JP drain placement into a new hepatic abscess, a repeat cholangiogram on ___ that showed good anterograde flow through the bare-metal stent in the CBD, and replacement of the right PTBD drain on ___. She will follow-up with interventional radiology upon discharge and pending repeat CT w/contrast of the abd/pelvis she will have the hepatic abscess drain removed. She will follow-up in 2 weeks with interventional radiology for possible side-by-side stenting of the left biliary system. #Hepatic abscess On arrival to hospital repeat CT abdomen pelvis showed new fluid collections from the right lobe of the liver worrisome for abscess, though she was initially started empirically on ceftriaxone and Flagyl and continued on suppressive Bactrim for history of ESBL E. coli. On ___ she had a drain placed in the hepatic dome, which later grew with sensitive to meropenem/ertapenem and ___ sensitive to fluconazole and the Bactrim was discontinued. She had a PICC line placement on ___ to receive IV ertapenem as an outpatient for at least 3 weeks, and she will continue with fluconazole for at least 3 weeks with follow-up in the infectious disease clinic tentatively on ___ #Type 2 diabetes Her home metformin was held while inpatient, however she had poor control of her glucose and her basal and bolus dose insulin was adjusted appropriately. Given her goals of care, to ultimately return home to ___, new outpatient insulin was not started on this admission; however her oral diabetic meds were increased to Metformin 1000mg BID and glipizide 5mg daily. #Acute on chronic normocytic anemia Patient was noted to have an anemia the initial CBC hematocrit of 32 however she was mostly in the mid to low ___ stay. She had an absolute reticulocyte count of 0.14 demonstrating an appropriate bone marrow response. There is no evidence of active bleeding. #Goals of care She remained full code during her hospital stay, but on review of outpatient records and discussion with the family she was being set up for hospice. Her husband, son, and the patient all understand the gravity situation and ultimately her goals would be to get out of the hospital spend as much time at home with her family, ultimately to return to ___. #Hypokalemia #Hypomagnesemia Patient had some electrolyte disturbances on admission which were monitored and addressed as needed. #Protein calorie malnutrition Patient was started on Ensure supplements while inpatient. CHRONIC/STABLE ISSUES: ========================= #Metastatic cholangiocarcinoma to the liver and lung Patient had a extrahepatic biliary tree resection and hepaticoduodenostomy at ___ in ___. She has not undergone chemotherapy and does not want to undergo chemotherapy. During that hospitalization she grew ESBL E. coli from her peritoneal culture. #Recent history of cholangitis with E. coli and group B strep bacteremia Patient was admitted in ___ for cholangitis, and ERCP was unable to be performed so she had to PTBD drains placed. She completed a course of antibiotics 3 days prior to arrival onset on this hospitalization. #COPD on 2 L home O2 She is not in exacerbation, continued on home O2 2 L and home inhalers. #Heart failure with preserved ejection fraction She was continued on her home torsemide 10 mg. # CODE: full # CONTACT: ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Tiotropium Bromide 1 CAP IH DAILY 4. Torsemide 10 mg PO DAILY 5. Ursodiol 300 mg PO BID 6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Discharge Medications: 1. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*0 2. GlipiZIDE 5 mg PO DAILY RX *glipizide 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 6. Aspirin 81 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Metoprolol Succinate XL 12.5 mg PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Tiotropium Bromide 1 CAP IH DAILY 11. Torsemide 10 mg PO DAILY 12. Ursodiol 300 mg PO BID 13. HELD- Sulfameth/Trimethoprim DS 1 TAB PO DAILY This medication was held. Do not restart Sulfameth/Trimethoprim DS until you see your infectious disease doctors ___: Home Discharge Diagnosis: Primary diagnosis: ================== PTBD drain leakage Liver abscess with ESBL E. coli and ___ 2 diabetes Acute on chronic normocytic anemia Secondary diagnoses: ===================== metastatic cholangiocarcinoma COPD Heart failure with preserved ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== -You were in the hospital because the drains in your belly were leaking and you had an infection in your liver WHAT HAPPENED IN THE HOSPITAL? ============================== -The drains in your belly were replaced to fix the leaking -A new drain was inserted to drain the infection in your liver -you were started on antibiotics and antifungals for the infection and needed a catheter in the arm to get antibiotic infusions when you leave the hospital WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please maintain the care of your drains as directed - Please continue to take all of your medications as directed - Please follow up with the ___ daily in order to receive your antibiotics. - Please follow up with the interventional radiologists regarding the drain. - Please follow up with all the appointments scheduled with your doctor - If you have any worsening drainage from around the catheter sites, please call your doctors ___ return to the hospital. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Team Followup Instructions: ___
[ "T85590A", "K750", "K831", "E43", "B3789", "C787", "C7800", "I5032", "D684", "Z681", "C240", "B9620", "J449", "Z9981", "Y738", "Y929", "D649", "E8342", "Z87891", "I110", "I50812", "Z794", "E1165", "Z515", "E876", "E861" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal Pain, Biliary Drain Leak Major Surgical or Invasive Procedure: [MASKED]: B/L PTBD exchange with upsize of L to [MASKED] F. U/S guided hepatic dome abscess drain placement ([MASKED]). [MASKED]: [MASKED] cholangiogram which showed left sided drain in good position, right sided PTBD upsized to [MASKED] [MASKED]: R PICC placement History of Present Illness: [MASKED] with history of COPD on 2L O2, DMII, CHF, and metastatic cholangiocarcinoma s/p PTBD with recent cholangitis who presents with diffuse abdominal pain and drainage from her PTBD site. She reports no symptoms apart from increased drainage from her tube sites. She denied fevers/chills, worsening abdominal pain, lightheadedness, chest pain, shortness of breath. Notably, she was recently admitted with cholangitis complicated by E. coli and Group D strep bacteremia. She had a failed ERCP on [MASKED] as GI was unable to gain access to prioximal biliary tree. She underwent [MASKED] percutaneous biliary drain placement with [MASKED]. TTE was obtained given group D strep bacteremia and was negative for vegetations. ID did not feel that TEE was necessary, given known source of infection and rapid clearance of blood cultures. She was initially treated with vanc/cefepime/flagyl, and transitioned to levofloxacin/flagyl at discharge per ID recommendations. She just completed a 2 week course of these antibiotics on [MASKED]. Her course was also notable for hypotension with systolics in the [MASKED], which may be her baseline. - In the ED, initial vitals were: T 98.2F HR 90 BP 84/59 RR 20 O2 97% 2L NC - Labs were notable for: WBC 9 Hgb 10.1 Plt 285 BMP overall unremarkable Mg 1.3 Alk phos 162 Lipase 248, other LFTs unremarkable Lactate 2.5 -> 1.6 UA with 18 leukocytes INR 1.5 - Studies were notable for: CXR Relatively rounded 2.6 cm locule of air in the right upper quadrant for which cross-sectional imaging is suggested. CT abdomen and pelvis with contrast 1. Biliary stent extending into the small bowel with interval placement of two percutaneous catheters, one traveling within and one traveling adjacent to the stent into the small bowel. 2. Multiple predominantly air filled collections within the right lobe of the liver worrisome for abscesses, new since [MASKED]. 3. Findings compatible with patient's metastatic cholangiocarcinoma with conglomerate soft tissue mass at the porta hepatis involving the duodenum and pancreatic head with adjacent adenopathy and severe narrowing of the main portal vein. Metastatic lesions in the liver which have slightly enlarged since prior. 4. Indeterminate right adrenal nodule, potentially metastatic. 5. Large stool burden throughout the colon. - The patient was given: 1.5 L IV LR IV Piperacillin-Tazobactam 4.5 g - [MASKED] were consulted: "Bilious leakage from insertion site of left PTBD. I attached to drainage bag for decompression. Will exchange." On arrival to the floor, she says she has no pain. The only thing bothering her is the discharge from around the drains. Past Medical History: COPD on 2L Home O2 Type 2 Diabetes Primary Hypertension Cholangiocarcinoma metastatic to liver/lung Right Sided CHF Hyponatremia Social History: [MASKED] Family History: Son: DM Mother: CAD->sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: [MASKED] Temp: 97.7 PO BP: 107/67 HR: 82 RR: 18 O2 sat: 96% O2 delivery: 3L GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. 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: Right and left biliary drains with leakage of yellow bilious liquid from left drain. Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: ========================= 24 HR Data (last updated [MASKED] @ 1211) Temp: 97.7 (Tm 98.9), BP: 94/61 (92-102/61-68), HR: 86 (86-112), RR: 16 ([MASKED]), O2 sat: 99% (98-100) General: [MASKED] speaking woman in no acute distress Cardiovascular: S1-S2 present, regular rate and rhythm, no murmurs rubs or gallops. Pulmonary: Clear to auscultation bilaterally Abdomen: Soft nontender nondistended. Non tender. minimal drainage on dressings, Biliary drains draining green fluid, JP drain with serosanguinous drainage. Extremities: Warm well perfused, no edema Pertinent Results: ADMISSION LABS: ============== [MASKED] 12:28PM BLOOD WBC-9.0 RBC-3.47* Hgb-10.1* Hct-32.0* MCV-92 MCH-29.1 MCHC-31.6* RDW-16.0* RDWSD-54.5* Plt [MASKED] [MASKED] 12:28PM BLOOD Neuts-82.3* Lymphs-7.2* Monos-7.7 Eos-0.4* Baso-0.6 Im [MASKED] AbsNeut-7.37* AbsLymp-0.64* AbsMono-0.69 AbsEos-0.04 AbsBaso-0.05 [MASKED] 12:28PM BLOOD [MASKED] PTT-35.5 [MASKED] [MASKED] 12:28PM BLOOD Glucose-116* UreaN-8 Creat-0.8 Na-134* K-3.8 Cl-87* HCO3-33* AnGap-14 [MASKED] 12:28PM BLOOD ALT-6 AST-23 AlkPhos-162* TotBili-1.0 [MASKED] 12:28PM BLOOD Lipase-248* [MASKED] 12:28PM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.2* Mg-1.3* [MASKED] 12:39PM BLOOD [MASKED] pO2-32* pCO2-56* pH-7.42 calTCO2-38* Base XS-9 Comment-GREEN TOP [MASKED] 12:39PM BLOOD Lactate-2.5* RELEVANT INTERVAL LABS: ===================== [MASKED] 11:09PM BLOOD WBC-4.8 RBC-2.15* Hgb-6.4* Hct-20.5* MCV-95 MCH-29.8 MCHC-31.2* RDW-18.1* RDWSD-62.2* Plt [MASKED] [MASKED] 04:50PM BLOOD Glucose-444* UreaN-13 Creat-0.5 Na-133* K-4.2 Cl-89* HCO3-30 AnGap-14 [MASKED] 06:03AM BLOOD ALT-7 AST-22 LD(LDH)-212 AlkPhos-212* TotBili-0.7 [MASKED] 05:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.4* [MASKED] 05:07AM BLOOD [MASKED] PTT-34.3 [MASKED] DISCHARGE LABS: ============== [MASKED] 05:28AM BLOOD WBC-6.0 RBC-2.72* Hgb-8.4* Hct-26.6* MCV-98 MCH-30.9 MCHC-31.6* RDW-18.0* RDWSD-63.7* Plt [MASKED] [MASKED] 05:28AM BLOOD Glucose-132* UreaN-18 Creat-0.5 Na-134* K-4.6 Cl-94* HCO3-28 AnGap-12 [MASKED] 05:28AM BLOOD AlkPhos-179* [MASKED] 05:28AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1 ============== MICROBIOLOGY: ============== [MASKED] 5:58 pm ABSCESS Source: liver abscess. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). Reported to and read back by [MASKED] AT 2211 ON [MASKED]. FLUID CULTURE (Final [MASKED]: IDENTIFICATION AND SUSCEPTIBILITIES ON ALL ORGANISMS ISOLATED PER [MASKED] ([MASKED]) [MASKED]. ESCHERICHIA COLI. SPARSE GROWTH. Ertapenem Susceptibility testing requested per [MASKED] [MASKED] ([MASKED]) [MASKED]. Ertapenem SUSCEPTIBLE test result performed by [MASKED] [MASKED]. TETRACYCLINE Susceptibility testing requested per [MASKED] [MASKED] [MASKED] ([MASKED]) [MASKED]. TETRACYCLINE test result performed by [MASKED]. ESCHERICHIA COLI. RARE GROWTH. [MASKED] MORPHOLOGY. Ertapenem Susceptibility testing requested per [MASKED] [MASKED] ([MASKED]) [MASKED]. Ertapenem SUSCEPTIBLE test result performed by [MASKED] [MASKED]. TETRACYCLINE Susceptibility testing requested per [MASKED] [MASKED] [MASKED] ([MASKED]) [MASKED]. TETRACYCLINE test result performed by [MASKED]. [MASKED] ALBICANS. SPARSE GROWTH. Yeast Susceptibility:. Fluconazole MIC OF 0.25 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. MIXED BACTERIAL FLORA. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- =>64 R =>64 R CEFTAZIDIME----------- =>64 R 16 I CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TETRACYCLINE---------- R R TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. =============== REPORTS: =============== [MASKED] CXR: Relatively rounded 2.6 cm locule of air in the right upper quadrant for which cross-sectional imaging is suggested. [MASKED] CT Abdomen/Pelvis w/contrast: 1. Biliary stent extending into the small bowel with interval placement of two percutaneous catheters, one traveling within and one traveling adjacent to the stent into the small bowel. 2. Multiple predominantly air filled collections within the right lobe of the liver worrisome for abscesses, new since [MASKED]. 3. Findings compatible with patient's metastatic cholangiocarcinoma with conglomerate soft tissue mass at the porta hepatis involving the duodenum and pancreatic head with adjacent adenopathy and severe narrowing of the main portal vein. Metastatic lesions in the liver which have slightly enlarged since prior. 4. Indeterminate right adrenal nodule, potentially metastatic. 5. Large stool burden throughout the colon. [MASKED] EXCHANGE BILIARY DRG CATH: -Successful exchange of bilateral internal external PTBDs with upsize of the left-sided drain to a 12 [MASKED] drain. Drains left open to gravity bag drainage. -Successful placement of an 8 [MASKED] pigtail drainage catheter into a hepatic dome abscess under ultrasound and fluoroscopic guidance connected to a JP drain. [MASKED] EXCHANGE BILIARY DRG CATH: -Satisfactory positioning of left-sided internal external PTB D -No intrahepatic biliary dilatation. -Bare metal stent in the common bile duct is patent with antegrade flow of contrast from the intrahepatic bile ducts through the stent and into the small bowel. -Filling of non dilated right posterior ducts on right-sided PTB D pull-back cholangiogram. These duct appear to drain centrally near the location of the bare metal stent. -Satisfactory positioning of new right-sided 12 [MASKED] internal external PTB D. [MASKED] CXR: PICC line terminating at the cavoatrial junction. [MASKED] EKG: SR, low voltage limb leads, TWI in lateral leads, QTc RIEF HOSPITAL COURSE: ========================= Ms. [MASKED] is a [MASKED] [MASKED] speaking woman with a history of COPD on 2 L home O2,type 2 diabetes, primarily right-sided CHF and metastatic colonic carcinoma status post hepaticoduodenostomy with placement of a bare-metal CBD stent in [MASKED], more recent admission for cholangitis status post right and left PTBD drains who presented with abdominal pain and leakage from the drains and was found to have a liver abscess. She had upsizing of both PTBD drains to prevent further leak, she had a JP drain placed in the liver abscess which grew E. coli multidrug resistance and [MASKED] she was started on meropenem and fluconazole. She had a PICC placement for at least 3 weeks of ertapenem and she will follow-up with infectious disease. We will plan to follow-up with interventional radiology for repeat CT scan 1 week after discharge to consider for removal of the liver abscess JP drain, and then 2 weeks after discharge for consideration of side-by-side stenting of the biliary system. TRANSITIONAL ISSUES: ========================= [ ] Ongoing goals of care discussion. Patient wants to spend as much time home and out of the hospital with her family, ideally to return to [MASKED] if possible [ ] Infectious disease: Right upper quadrant ultrasound the liver first week of [MASKED]. [ ] Follow-up in [MASKED] clinic, [MASKED]. [ ] Will need to come to [MASKED] for daily infusions of ertapenem 1 g daily IV for at least 3 weeks. Tentative plan for [MASKED] through [MASKED] at infusion clinic and [MASKED] at hematology/oncology. [ ] Continue fluconazole 400 mg daily for at least 3 weeks [ ] Interventional radiology: Follow-up for removal of JP drain following repeat imaging, she will need a repeat CT with contrast of the abdomen and pelvis [ ] Interventional radiology: Follow-up in 2 weeks for potential side-by-side stenting of left biliary system on [MASKED] [ ] consider uptitrating glipizide for better blood sugar control. ACUTE/ACTIVE ISSUES: ========================= #Biliary drain leakage Patient had a recent PTBD drain placement in the setting of cholangitis, however she returned with abdominal pain and some leakage from the drain sites. She had a replacement of the left PTBD drains on [MASKED] and the JP drain placement into a new hepatic abscess, a repeat cholangiogram on [MASKED] that showed good anterograde flow through the bare-metal stent in the CBD, and replacement of the right PTBD drain on [MASKED]. She will follow-up with interventional radiology upon discharge and pending repeat CT w/contrast of the abd/pelvis she will have the hepatic abscess drain removed. She will follow-up in 2 weeks with interventional radiology for possible side-by-side stenting of the left biliary system. #Hepatic abscess On arrival to hospital repeat CT abdomen pelvis showed new fluid collections from the right lobe of the liver worrisome for abscess, though she was initially started empirically on ceftriaxone and Flagyl and continued on suppressive Bactrim for history of ESBL E. coli. On [MASKED] she had a drain placed in the hepatic dome, which later grew with sensitive to meropenem/ertapenem and [MASKED] sensitive to fluconazole and the Bactrim was discontinued. She had a PICC line placement on [MASKED] to receive IV ertapenem as an outpatient for at least 3 weeks, and she will continue with fluconazole for at least 3 weeks with follow-up in the infectious disease clinic tentatively on [MASKED] #Type 2 diabetes Her home metformin was held while inpatient, however she had poor control of her glucose and her basal and bolus dose insulin was adjusted appropriately. Given her goals of care, to ultimately return home to [MASKED], new outpatient insulin was not started on this admission; however her oral diabetic meds were increased to Metformin 1000mg BID and glipizide 5mg daily. #Acute on chronic normocytic anemia Patient was noted to have an anemia the initial CBC hematocrit of 32 however she was mostly in the mid to low [MASKED] stay. She had an absolute reticulocyte count of 0.14 demonstrating an appropriate bone marrow response. There is no evidence of active bleeding. #Goals of care She remained full code during her hospital stay, but on review of outpatient records and discussion with the family she was being set up for hospice. Her husband, son, and the patient all understand the gravity situation and ultimately her goals would be to get out of the hospital spend as much time at home with her family, ultimately to return to [MASKED]. #Hypokalemia #Hypomagnesemia Patient had some electrolyte disturbances on admission which were monitored and addressed as needed. #Protein calorie malnutrition Patient was started on Ensure supplements while inpatient. CHRONIC/STABLE ISSUES: ========================= #Metastatic cholangiocarcinoma to the liver and lung Patient had a extrahepatic biliary tree resection and hepaticoduodenostomy at [MASKED] in [MASKED]. She has not undergone chemotherapy and does not want to undergo chemotherapy. During that hospitalization she grew ESBL E. coli from her peritoneal culture. #Recent history of cholangitis with E. coli and group B strep bacteremia Patient was admitted in [MASKED] for cholangitis, and ERCP was unable to be performed so she had to PTBD drains placed. She completed a course of antibiotics 3 days prior to arrival onset on this hospitalization. #COPD on 2 L home O2 She is not in exacerbation, continued on home O2 2 L and home inhalers. #Heart failure with preserved ejection fraction She was continued on her home torsemide 10 mg. # CODE: full # CONTACT: [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Tiotropium Bromide 1 CAP IH DAILY 4. Torsemide 10 mg PO DAILY 5. Ursodiol 300 mg PO BID 6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Discharge Medications: 1. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*0 2. GlipiZIDE 5 mg PO DAILY RX *glipizide 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 6. Aspirin 81 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Metoprolol Succinate XL 12.5 mg PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Tiotropium Bromide 1 CAP IH DAILY 11. Torsemide 10 mg PO DAILY 12. Ursodiol 300 mg PO BID 13. HELD- Sulfameth/Trimethoprim DS 1 TAB PO DAILY This medication was held. Do not restart Sulfameth/Trimethoprim DS until you see your infectious disease doctors [MASKED]: Home Discharge Diagnosis: Primary diagnosis: ================== PTBD drain leakage Liver abscess with ESBL E. coli and [MASKED] 2 diabetes Acute on chronic normocytic anemia Secondary diagnoses: ===================== metastatic cholangiocarcinoma COPD Heart failure with preserved ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== -You were in the hospital because the drains in your belly were leaking and you had an infection in your liver WHAT HAPPENED IN THE HOSPITAL? ============================== -The drains in your belly were replaced to fix the leaking -A new drain was inserted to drain the infection in your liver -you were started on antibiotics and antifungals for the infection and needed a catheter in the arm to get antibiotic infusions when you leave the hospital WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please maintain the care of your drains as directed - Please continue to take all of your medications as directed - Please follow up with the [MASKED] daily in order to receive your antibiotics. - Please follow up with the interventional radiologists regarding the drain. - Please follow up with all the appointments scheduled with your doctor - If you have any worsening drainage from around the catheter sites, please call your doctors [MASKED] return to the hospital. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I5032", "J449", "Y929", "D649", "Z87891", "I110", "Z794", "E1165", "Z515" ]
[ "T85590A: Other mechanical complication of bile duct prosthesis, initial encounter", "K750: Abscess of liver", "K831: Obstruction of bile duct", "E43: Unspecified severe protein-calorie malnutrition", "B3789: Other sites of candidiasis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "I5032: Chronic diastolic (congestive) heart failure", "D684: Acquired coagulation factor deficiency", "Z681: Body mass index [BMI] 19.9 or less, adult", "C240: Malignant neoplasm of extrahepatic bile duct", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "J449: Chronic obstructive pulmonary disease, unspecified", "Z9981: Dependence on supplemental oxygen", "Y738: Miscellaneous gastroenterology and urology devices associated with adverse incidents, not elsewhere classified", "Y929: Unspecified place or not applicable", "D649: Anemia, unspecified", "E8342: Hypomagnesemia", "Z87891: Personal history of nicotine dependence", "I110: Hypertensive heart disease with heart failure", "I50812: Chronic right heart failure", "Z794: Long term (current) use of insulin", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z515: Encounter for palliative care", "E876: Hypokalemia", "E861: Hypovolemia" ]
10,052,938
25,231,169
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: sepsis, choalngiocarcinoma, bile duct obstruction Major Surgical or Invasive Procedure: ERCP (Endoscopic Retrograde Cholangiopancreatography) Percutaneous biliary drain placement History of Present Illness: ___ year old Female from ___ here for ERCP, due to bile duct obstruction from invasive metastatic cholangiocarcinoma. The patient had resection of the tumor with positive margins, with liver metastases, ultimately required a hepaticoduodenostmy. She previously had a uncovered metal stent placed due to biliary obstruction from the tumor. On this admission she presented to ___ with fever, hypotension, bilirubin of 3.7 and ultimately had positive blood cultures with gram negative rods. Sent over for restenting via ERCP here at ___ initially planned as round-trip. However ERCP failed due to inability to pass the wire past the tumor which has grown through the stent. She is now admitted to ___ does not have an ___ service that can do a PTBD placement in this acutely ill a patient. On arrival to the floor she presents hypotensive. Prior to transfer she was given flagyl, Vancomycin, cefepime. Per the CHA notes she was rigoring with a Tmax 102.4. The patient was initially diagnosed with cholangiocarcinoma in ___. 2 weeks prior to this admission she was admitted to ___ with 2 weeks of abdominal pain, nausea/vomiting,, elevated lipase, which showed a mass at the pancreatic head likely obstructing, along with CT demonstrating liver and lung mets (new), the patient was ultimately discharged after her pain improved and referred to hospice. On this presentation to ___ she presents with fever, nausea/vomiting and RUQ pain. She also notes worsened cough productive of white sputum. Initial vitals there were T102.4, HR 140s, BP 91/59. An initial CXR concerning for possible LLL pneumonia. And she was given vancomycin/cefepime for HCAP. Past Medical History: COPD on 2L Home O2 Type 2 Diabetes Primary Hypertension Cholangiocarcinoma metastatic to liver/lung Right Sided CHF Hyponatremia Social History: ___ Family History: Son: DM Mother: CAD->sudden cardiac death Physical Exam: Admission Physical Exam: ======================== VSS: 97.6, 88/58, 92, 18, 95%2LNC GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: Crackled to mid lung on left COR: RRR, S1/S2, - MRG ABD: Moderate RUQ TTP, - Rebound, - Guarding, ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Discharge Physical Exam: ======================== Vitals: see Eflowsheets General: Alert, oriented x3. No acute distress. Wearing NC. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI CV: Mild tachycardia, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar lower lobe crackles, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley, perc site bandage c/d/I, drain capped Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Face grossly symmetric. Moving all limbs with purpose against gravity. Not dysarthric. Pertinent Results: Admission Labs: =============== ___ 05:39AM BLOOD WBC-5.5 RBC-2.57* Hgb-7.4* Hct-23.6* MCV-92 MCH-28.8 MCHC-31.4* RDW-15.7* RDWSD-53.1* Plt Ct-89* ___ 05:39AM BLOOD Neuts-86.6* Lymphs-6.0* Monos-6.0 Eos-0.5* Baso-0.2 Im ___ AbsNeut-4.79 AbsLymp-0.33* AbsMono-0.33 AbsEos-0.03* AbsBaso-0.01 ___ 05:39AM BLOOD Glucose-137* UreaN-9 Creat-0.7 Na-140 K-3.5 Cl-110* HCO3-22 AnGap-8* ___ 05:39AM BLOOD ALT-92* AST-105* AlkPhos-189* TotBili-2.2* ___ 05:39AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1 Discharge Labs: =============== ___ 05:49AM BLOOD WBC-6.4 RBC-2.97* Hgb-8.4* Hct-26.2* MCV-88 MCH-28.3 MCHC-32.1 RDW-15.6* RDWSD-50.4* Plt ___ ___ 05:49AM BLOOD Glucose-130* UreaN-6 Creat-0.5 Na-141 K-3.6 Cl-103 HCO3-23 AnGap-15 ___ 05:49AM BLOOD ALT-31 AST-14 AlkPhos-148* TotBili-0.9 ___ 05:49AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.5* Brief Hospital Course: ___ with a history of metastatic cholangiocarcinoma who presented with hypotension, fevers, chills, found to have cholangitis with GNR and group D strep bacteremia in the setting of biliary duct obstruction, now s/p ___ guided perc biliary drain placement. # Gram Negative Sepsis due to Cholangitis # Cholangiocarcinoma metastatic to liver/Lung # Bacteremia: Hx of cholangiocarcinoma, s/p extrahepatic biliary tree resection with hepaticoduodenostomy at ___ in late ___. Had recent admission for abdominal pain, ultimately found to have imaging findings consistent with progression of cholangiocarcinoma. She re-presented to ___ and was found to have likely cholangitis. Blood cultures grew E.Coli (sensitive to cefepime) and Group D Strep species. Re-presented to ___. She was transferred to ___ for ERCP. Had failed ERCP done ___: GI unable to gain access to proximal biliary tree as prior stent clogged with tumor ingrowth. She underwent ___ percutaneous biliary drain placement with ___. TTE was obtained given group D strep bacteremia and was negative for vegetations. ID did not feel that TEE was necessary, given known source of infection and rapid clearance of blood cultures. She was initially treated with vanc/cefepime/flagyl, and transitioned to levofloxacin/flagyl at discharge per ID recommendations. She will require a two week total antibiotic course for bacteremia (day 14 = ___. Drains were capped by ___ prior to discharge. She will require ___ follow up in four weeks for cholangiocarcinoma and possible stenting. # Hypotension: secondary to sepsis. Required brief ICU stay post drain placement. She received 1L of IV fluid with resolution of hypotension. Home anti-hypertensives were initially held. Metoprolol and torsemide were restarted prior to discharge. Continued to hold 2.5mg of lisinopril as blood pressures remained in the low-normal range # ? Pneumonia CXR on ___ with patchy opacities (atelectasis v PNA). This was felt to be likely atelectasis due to splinting in the setting of abdominal pain. She did complete > 5 days of antibiotics as above which also covered for any concurrent pneumonia. # Acute on Chronic Anemia (resolving) Hgb on admission 7.4, decreased to 6.8 post-procedure. Transfused 1 unit pRBCs with appropriate Hgb response to 9.1. She had no signs of active bleeding and Hg remained stable for remainder of hospital course # Cholangiocarcinoma: metastatic, with progression on recent imaging. She will follow up with her outpatient oncologist next week for discussion of palliative chemotherapy vs. transition to hospice #Transitional Issue [ ] Subcentimeter pulmonary nodules which were not present on the previous exam. These are nonspecific, though metastatic disease is not excluded in this patient with cholangiocarcinoma. Further evaluation/follow-up per oncologic protocol. She will follow up with oncology as above, but per patient's sign plan is to likely decline chemotherapy # Diabetes: held home metformin. Placed on ISS while hospitalized # COPD (on 2L O2 at home, former smoker): continued home inhalers and 2L oxygen # HFpEF Hx of R side HF, not volume overloaded on exam. Restarted home torsemide after hypotension resolved. > 30 minutes spent on discharge coordination and planning Transitional Issues: ==================== - discharged on levofloxacin/flagyl for 14 day course for cholangitis/bacteremia (day ___ = ___ - needs ___ follow up in four weeks for cholangigram, discussion of possible stent - she will follow up with oncology as an outpatient for discussion of palliative chemotherapy vs. transition to hospice Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Tiotropium Bromide 1 CAP IH DAILY 6. Ursodiol 300 mg PO BID 7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 8. Aspirin 81 mg PO DAILY 9. Lisinopril 2.5 mg PO DAILY 10. Torsemide 10 mg PO DAILY Discharge Medications: 1. LevoFLOXacin 500 mg PO Q24H *AST Approval Required* RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*9 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*28 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 4. Aspirin 81 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 9. Tiotropium Bromide 1 CAP IH DAILY 10. Torsemide 10 mg PO DAILY 11. Ursodiol 300 mg PO BID 12. HELD- Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line This medication was held. Do not restart Ondansetron until you finish taking levofloxacin (these medications can interact) Discharge Disposition: Home Discharge Diagnosis: Primary: Cholangitis Metastatic cholangiocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came into the hospital because you were having fevers and abdominal pain. We found that you had an infection in your abdomen that had spread to your blood. This infection was caused by a blockage in your bile duct. You had a drain placed to open the blockage, and you were treated with antibiotics. It will be very important to continue taking the antibiotics until ___. If you stop taking the antibiotics then the infection may come back. The drain in your abdomen will have to stay in place until you follow up with the radiologists in clinic. Someone should call you with an appointment. If you do not hear from anyone within a week, please call the ___ clinic at ___ to schedule an appointment. It will also be important to follow up with Dr. ___ Dr. ___. Dr. ___ office is working on rescheduling your appointment. It was a pleasure taking care of you, and we are happy that you're feeling better! Followup Instructions: ___
[ "A4181", "K831", "J189", "C221", "C787", "I110", "C7800", "I5032", "J440", "K8309", "A4151", "Z9049", "E119", "Z7984", "Z9981", "Z87891", "I959", "Y95", "I50812", "Z792", "Z1612", "D649", "D6959" ]
Allergies: No Allergies/ADRs on File Chief Complaint: sepsis, choalngiocarcinoma, bile duct obstruction Major Surgical or Invasive Procedure: ERCP (Endoscopic Retrograde Cholangiopancreatography) Percutaneous biliary drain placement History of Present Illness: [MASKED] year old Female from [MASKED] here for ERCP, due to bile duct obstruction from invasive metastatic cholangiocarcinoma. The patient had resection of the tumor with positive margins, with liver metastases, ultimately required a hepaticoduodenostmy. She previously had a uncovered metal stent placed due to biliary obstruction from the tumor. On this admission she presented to [MASKED] with fever, hypotension, bilirubin of 3.7 and ultimately had positive blood cultures with gram negative rods. Sent over for restenting via ERCP here at [MASKED] initially planned as round-trip. However ERCP failed due to inability to pass the wire past the tumor which has grown through the stent. She is now admitted to [MASKED] does not have an [MASKED] service that can do a PTBD placement in this acutely ill a patient. On arrival to the floor she presents hypotensive. Prior to transfer she was given flagyl, Vancomycin, cefepime. Per the CHA notes she was rigoring with a Tmax 102.4. The patient was initially diagnosed with cholangiocarcinoma in [MASKED]. 2 weeks prior to this admission she was admitted to [MASKED] with 2 weeks of abdominal pain, nausea/vomiting,, elevated lipase, which showed a mass at the pancreatic head likely obstructing, along with CT demonstrating liver and lung mets (new), the patient was ultimately discharged after her pain improved and referred to hospice. On this presentation to [MASKED] she presents with fever, nausea/vomiting and RUQ pain. She also notes worsened cough productive of white sputum. Initial vitals there were T102.4, HR 140s, BP 91/59. An initial CXR concerning for possible LLL pneumonia. And she was given vancomycin/cefepime for HCAP. Past Medical History: COPD on 2L Home O2 Type 2 Diabetes Primary Hypertension Cholangiocarcinoma metastatic to liver/lung Right Sided CHF Hyponatremia Social History: [MASKED] Family History: Son: DM Mother: CAD->sudden cardiac death Physical Exam: Admission Physical Exam: ======================== VSS: 97.6, 88/58, 92, 18, 95%2LNC GEN: NAD Pain: [MASKED] HEENT: EOMI, MMM, - OP Lesions PUL: Crackled to mid lung on left COR: RRR, S1/S2, - MRG ABD: Moderate RUQ TTP, - Rebound, - Guarding, ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Discharge Physical Exam: ======================== Vitals: see Eflowsheets General: Alert, oriented x3. No acute distress. Wearing NC. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI CV: Mild tachycardia, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar lower lobe crackles, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley, perc site bandage c/d/I, drain capped Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Face grossly symmetric. Moving all limbs with purpose against gravity. Not dysarthric. Pertinent Results: Admission Labs: =============== [MASKED] 05:39AM BLOOD WBC-5.5 RBC-2.57* Hgb-7.4* Hct-23.6* MCV-92 MCH-28.8 MCHC-31.4* RDW-15.7* RDWSD-53.1* Plt Ct-89* [MASKED] 05:39AM BLOOD Neuts-86.6* Lymphs-6.0* Monos-6.0 Eos-0.5* Baso-0.2 Im [MASKED] AbsNeut-4.79 AbsLymp-0.33* AbsMono-0.33 AbsEos-0.03* AbsBaso-0.01 [MASKED] 05:39AM BLOOD Glucose-137* UreaN-9 Creat-0.7 Na-140 K-3.5 Cl-110* HCO3-22 AnGap-8* [MASKED] 05:39AM BLOOD ALT-92* AST-105* AlkPhos-189* TotBili-2.2* [MASKED] 05:39AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1 Discharge Labs: =============== [MASKED] 05:49AM BLOOD WBC-6.4 RBC-2.97* Hgb-8.4* Hct-26.2* MCV-88 MCH-28.3 MCHC-32.1 RDW-15.6* RDWSD-50.4* Plt [MASKED] [MASKED] 05:49AM BLOOD Glucose-130* UreaN-6 Creat-0.5 Na-141 K-3.6 Cl-103 HCO3-23 AnGap-15 [MASKED] 05:49AM BLOOD ALT-31 AST-14 AlkPhos-148* TotBili-0.9 [MASKED] 05:49AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.5* Brief Hospital Course: [MASKED] with a history of metastatic cholangiocarcinoma who presented with hypotension, fevers, chills, found to have cholangitis with GNR and group D strep bacteremia in the setting of biliary duct obstruction, now s/p [MASKED] guided perc biliary drain placement. # Gram Negative Sepsis due to Cholangitis # Cholangiocarcinoma metastatic to liver/Lung # Bacteremia: Hx of cholangiocarcinoma, s/p extrahepatic biliary tree resection with hepaticoduodenostomy at [MASKED] in late [MASKED]. Had recent admission for abdominal pain, ultimately found to have imaging findings consistent with progression of cholangiocarcinoma. She re-presented to [MASKED] and was found to have likely cholangitis. Blood cultures grew E.Coli (sensitive to cefepime) and Group D Strep species. Re-presented to [MASKED]. She was transferred to [MASKED] for ERCP. Had failed ERCP done [MASKED]: GI unable to gain access to proximal biliary tree as prior stent clogged with tumor ingrowth. She underwent [MASKED] percutaneous biliary drain placement with [MASKED]. TTE was obtained given group D strep bacteremia and was negative for vegetations. ID did not feel that TEE was necessary, given known source of infection and rapid clearance of blood cultures. She was initially treated with vanc/cefepime/flagyl, and transitioned to levofloxacin/flagyl at discharge per ID recommendations. She will require a two week total antibiotic course for bacteremia (day 14 = [MASKED]. Drains were capped by [MASKED] prior to discharge. She will require [MASKED] follow up in four weeks for cholangiocarcinoma and possible stenting. # Hypotension: secondary to sepsis. Required brief ICU stay post drain placement. She received 1L of IV fluid with resolution of hypotension. Home anti-hypertensives were initially held. Metoprolol and torsemide were restarted prior to discharge. Continued to hold 2.5mg of lisinopril as blood pressures remained in the low-normal range # ? Pneumonia CXR on [MASKED] with patchy opacities (atelectasis v PNA). This was felt to be likely atelectasis due to splinting in the setting of abdominal pain. She did complete > 5 days of antibiotics as above which also covered for any concurrent pneumonia. # Acute on Chronic Anemia (resolving) Hgb on admission 7.4, decreased to 6.8 post-procedure. Transfused 1 unit pRBCs with appropriate Hgb response to 9.1. She had no signs of active bleeding and Hg remained stable for remainder of hospital course # Cholangiocarcinoma: metastatic, with progression on recent imaging. She will follow up with her outpatient oncologist next week for discussion of palliative chemotherapy vs. transition to hospice #Transitional Issue [ ] Subcentimeter pulmonary nodules which were not present on the previous exam. These are nonspecific, though metastatic disease is not excluded in this patient with cholangiocarcinoma. Further evaluation/follow-up per oncologic protocol. She will follow up with oncology as above, but per patient's sign plan is to likely decline chemotherapy # Diabetes: held home metformin. Placed on ISS while hospitalized # COPD (on 2L O2 at home, former smoker): continued home inhalers and 2L oxygen # HFpEF Hx of R side HF, not volume overloaded on exam. Restarted home torsemide after hypotension resolved. > 30 minutes spent on discharge coordination and planning Transitional Issues: ==================== - discharged on levofloxacin/flagyl for 14 day course for cholangitis/bacteremia (day [MASKED] = [MASKED] - needs [MASKED] follow up in four weeks for cholangigram, discussion of possible stent - she will follow up with oncology as an outpatient for discussion of palliative chemotherapy vs. transition to hospice Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Tiotropium Bromide 1 CAP IH DAILY 6. Ursodiol 300 mg PO BID 7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 8. Aspirin 81 mg PO DAILY 9. Lisinopril 2.5 mg PO DAILY 10. Torsemide 10 mg PO DAILY Discharge Medications: 1. LevoFLOXacin 500 mg PO Q24H *AST Approval Required* RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*9 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*28 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 4. Aspirin 81 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 9. Tiotropium Bromide 1 CAP IH DAILY 10. Torsemide 10 mg PO DAILY 11. Ursodiol 300 mg PO BID 12. HELD- Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line This medication was held. Do not restart Ondansetron until you finish taking levofloxacin (these medications can interact) Discharge Disposition: Home Discharge Diagnosis: Primary: Cholangitis Metastatic cholangiocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came into the hospital because you were having fevers and abdominal pain. We found that you had an infection in your abdomen that had spread to your blood. This infection was caused by a blockage in your bile duct. You had a drain placed to open the blockage, and you were treated with antibiotics. It will be very important to continue taking the antibiotics until [MASKED]. If you stop taking the antibiotics then the infection may come back. The drain in your abdomen will have to stay in place until you follow up with the radiologists in clinic. Someone should call you with an appointment. If you do not hear from anyone within a week, please call the [MASKED] clinic at [MASKED] to schedule an appointment. It will also be important to follow up with Dr. [MASKED] Dr. [MASKED]. Dr. [MASKED] office is working on rescheduling your appointment. It was a pleasure taking care of you, and we are happy that you're feeling better! Followup Instructions: [MASKED]
[]
[ "I110", "I5032", "E119", "Z87891", "D649" ]
[ "A4181: Sepsis due to Enterococcus", "K831: Obstruction of bile duct", "J189: Pneumonia, unspecified organism", "C221: Intrahepatic bile duct carcinoma", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "I110: Hypertensive heart disease with heart failure", "C7800: Secondary malignant neoplasm of unspecified lung", "I5032: Chronic diastolic (congestive) heart failure", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "K8309: Other cholangitis", "A4151: Sepsis due to Escherichia coli [E. coli]", "Z9049: Acquired absence of other specified parts of digestive tract", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z9981: Dependence on supplemental oxygen", "Z87891: Personal history of nicotine dependence", "I959: Hypotension, unspecified", "Y95: Nosocomial condition", "I50812: Chronic right heart failure", "Z792: Long term (current) use of antibiotics", "Z1612: Extended spectrum beta lactamase (ESBL) resistance", "D649: Anemia, unspecified", "D6959: Other secondary thrombocytopenia" ]
10,052,992
21,083,113
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bright red blood in stools Major Surgical or Invasive Procedure: None. History of Present Illness: PCP: ___. ___ -- ___ (___) CC: ___ bleeding HISTORY OF PRESENT ILLNESS: =========================== Mr. ___ is a ___ with history of HTN, HLD, CRC s/p sigmoidectomy/FOLFOX (___) and HCV + HBV c/b cirrhosis and HCC s/p resection/adjuvant chemo c/b recurrence and lung mets (___) who presents with BRBPR in setting of anticoagulation for recent PE. History taken from son and chart. Mr. ___ was discharged from ___ ___ for hospitalization where he was found to have metastatic HCC to the lung as well as new PE. He was discharged on 3 days of Lovenox, with instructions to switch to apixaban on ___. Son reports that patient only just filled the apixaban script prior to presenting to the ED on ___ and has not been taking any anticoagulation since his Lovenox ran out on ___. By report, the patient has been experiencing rectal urgency and tenesmus for the last ~20 days. 3 days PTA, he began noticing blood in the toilet bowl. Since then, he has been having ___ very small bowel movements per day, all with bright red blood. He denies pain with defecation, lightheadedness or presyncope, and his appetite is minimal at baseline. He endorses 2 episodes of non-bloody emesis- toward the end of his second episode he had streaks of emesis but no frank blood. He denies generalized itchiness and his son reports he does not look more jaundiced than usual. He reports ~10 days of mild hemoptysis that he attributed to his lung met, but he has not had any hemoptysis since the rectal bleeding began. Yesterday morning (in the ED) he began experiencing ___ right frontal headaches that are non-positional and do not change withneck flexion, as well as mild lower abdominal/suprapubic pain. He had a paracentesis ___ with removal 3.4L, negative for SBP - PMNs 60. Since then his son reports that his abdominal swelling has slowly re-accumulated but is not as tense or distended as it was prior to the paracentesis. He does not get regular paracenteses. In the ED, vitals were: T 96.7 HR 76 BP 113/77 RR 18 O2 Sat 98% RA Exam: No acute distress RRR, no m/r/g Lungs CTAB Distended abdomen w/ ascites, nontender No spider angiomas/nail changes No asterixis Labs: CBC: WBC 3.4, Hb 11.6 from nadir of 10.8, Plt 89 BMP: Na 137, K 4.9, Cl 110, HCO3 19, BUN 14, Cr 1.0, Ca 8.2, Mg 2.4, Ph 1.9 LFT: ALT 176, AST 685, AP 238, Tbili 7.7. Alb 2.5 Lactate 2.4 UA with 2+ urobilinogen, otherwie unremarkable UCx pending Studies: Colonoscopy ___: internal hemorrhoids, no active bleeding. Also showed small angiodysplasia and submucosal mass RUQUS ___ 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. He was given: For GIB: 2L LR, CTX 1g IV (ppx) For BP: home amlodipine He also got fleet enema in preparation for his colonoscopy. On arrival to the floor, patient reports that he has ___ headache which is improved compared to the ED. He also reports a little abdominal discomfort and fullness. He feels cold which is his baseline. He does not have any dizziness or lightheadedness. He does not have any blurred vision, palpitations, or shortness of breath. He denies any fever, chills or sweats. No abdominal pain. His last bowel movement was ___ in the evening. He has not had anything to drink for most of the day. Past Medical History: HCV HBV Cirrhosis HCC s/p resection (___) and RFA (___) c/b recurrence and lung mets (___) Colon CA stage 3B KRAS+ s/p sigmoid colectomy and adjuvant chemo (___) Acute cholecystitis s/p CCY ___ HTN Dyslipidemia GERD Hearing loss Social History: ___ Family History: No pertinent family history Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 98.2, HR 75, BP 120/79, RR 18, SpO2 97% RA GENERAL: Alert and interactive. In no acute distress. ___. HEENT: PERRL, EOMI. MMM. Sclera and soft palate are icteric. Bilateral hearing aids in place. Wearing glasses. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, no organomegaly. Abdomen is visibly distended with shifting dullness to percussion. No tenderness to deep palpation in ___ quadrants or suprapubic EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Diffusely jaundiced with some palmar erythema, no spider angiomata. Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3 but confused about longterm history. Defers to son. Moving all 4 limbs spontaneously. CN2-12 intact.Normal sensation. No asterixis DISCHARGE PHYSCIAL EXAM ======================== 24 HR Data (last updated ___ @ 024) Temp: 98.2 (Tm 98.2), BP: 109/62 (102-115/62-75), HR: 78 (78-82), RR: 18 (___), O2 sat: 95% (95-98), O2 delivery: RA GENERAL: NAD, ___. Son at bedside. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA. CTAB. ABDOMEN: well-healed scar in RUQ from prior procedure. Firm particularly in RUQ, mildly distended, no ttp. EXTREMITIES: Trace ___. SKIN: Diffusely jaundiced in lower extremities. NEUROLOGIC: Awake, not oriented to time (per son, this is baseline). No focal neurologic deficits. Normal gait. Pertinent Results: ADMISSION LABS: ___ 06:15PM BLOOD WBC-4.6 RBC-4.17* Hgb-13.1* Hct-39.0* MCV-94 MCH-31.4 MCHC-33.6 RDW-30.5* RDWSD-102.2* Plt ___ ___ 06:15PM BLOOD Neuts-59.8 Lymphs-17.2* Monos-14.9* Eos-3.4 Baso-1.5* Im ___ AbsNeut-2.77 AbsLymp-0.80* AbsMono-0.69 AbsEos-0.16 AbsBaso-0.___ 06:15PM BLOOD ___ PTT-38.1* ___ ___ 06:15PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-137 K-4.9 Cl-105 HCO3-21* AnGap-11 ___ 06:15PM BLOOD ALT-176* AST-685* AlkPhos-238* TotBili-7.7* ___ 07:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.8 ___ 06:27AM BLOOD calTIBC-122* Ferritn-397 TRF-94* ___ 06:27AM BLOOD IgM HAV-NEG ___ 07:45AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT ___ 08:06AM BLOOD pO2-70* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Comment-GREEN TOP ___ 06:24PM BLOOD Lactate-2.8* ___ 12:13AM BLOOD Lactate-3.3* ___ 03:04AM BLOOD Lactate-3.0* ___ 03:25PM BLOOD Lactate-2.4* ___ 08:06AM BLOOD Lactate-2.0 DISCHARGE LABS: ___ 07:35AM BLOOD WBC-5.1 RBC-3.01* Hgb-9.8* Hct-29.2* MCV-97 MCH-32.6* MCHC-33.6 RDW-32.1* RDWSD-110.6* Plt Ct-65* ___ 07:35AM BLOOD Glucose-108* UreaN-17 Creat-1.1 Na-141 K-4.1 Cl-112* HCO3-21* AnGap-8* MICRO: ___ 3:16 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 3:16 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. REPORTS: ___ PERITONEAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS ___ LIVER U/S: 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. ___ COLONOSCOPY: POLYPS IN COLON, ANGIOECTASIAS IN COLON, INTERNAL HEMMORHOIDS, PREVIOUS SURGERY IN COLON. Brief Hospital Course: Mr. ___ is a ___ y.o. male patient with HBC, HCV cirrhosis c/b HCC with newly diagnosed lung mets (___), s/p resection ___, RFA to segment VIII lesions, RFA to recurrent lesion ___, adenocarcinoma of colon (s/p sigmoid colectomy and FOLFOX ___, and non-occlusive L portal vein thrombus who was recently admitted for acute RLL subsegmental PE from ___ and re-admitted on ___ for BRBPR likely ___ internal hemorrhoids. Given metastatic HCC, new lesion c/f recurrence of colon adenocarcinoma, all c/b acute PE, Palliative Care was consulted and family decision was made to make pt DNR/DNI with plan to transition to home with hospice. ACUTE ISSUES: ============= # Rectal bleeding # Normocytic anemia # History of colon cancer s/p sigmoid resection in ___ in ___ + FOLFOX: Stage IIIB, T3N1cM0 ___ # New 2cm lesion in neo-sigmoid colon ___ CT abd) Patient presenting with BRBPR likely ___ internal hemorrhoids though possibly also rectal varices given cirrhosis. ___ colonoscopy notable for internal hemorrhoids, non-bleeding angioectasias in colon. Of note patient also restarted apixaban for cancer-associated PE, but did not take this due to inability to fill the medication. He was initially started on hep gtt and apixaban for recent diagnosis of PE, but this was discontinued on ___ given ongoing BRBPR. He continued to have ongoing BRBPR, but reported this decreased compared to admission. He was hemodynamically stable and did not require any transfusions during his hospitalization. #Recent dx PE We discussed the risks of not angicoagulating, to which pt's son agreed to stopping anticoagulation given ongoing BRBPR. # Decompensated cirrhosis c/b coagulopathy # ___ s/p liver resection in ___ ___ # History of HBC and HCV Patient has a long h/o cirrhosis ___ viral hepatitis (HCV and HBV) and c/b HCC. Has historically been well-compensated but presents now in decompensation i/s/o hyperbilirubinemia, elevated LFTs and tumor markers, and coagulopathy. He has a h/o ascites with last outpatient paracentesis on ___, with removal of 3.4L; studies negative for SBP. Repeat para on ___ removed ~2L fluid while inpatient and studies neg for SBP. He was started on PO Lasix 20mg qd + PO spironolactone 50mg qd (___) for abd distension discomfort. #GOC After discussion w/ Pall Care on ___, decision was made to make pt DNR/DNI and plan for home with hospice. He continues to have repeated episodes of BRBPR, though appears to have improved after stopping apixaban for PE. They prefer to have a hospice agency that works with ___ pts. DNR/DNI as of ___. MOLST in chart. #Hemoptysis Presented with blood-tinged sputum during this admission, reportedly had this in the past as well. Likely ___ re-starting AC, though improving. Predisposed to bleeding given pt has cirrhosis, coagulopathy. Per pt, this resolved. # Elevated lactate: 2.8 on arrival increased to 3.0 and then back down to 2.4 with some fluids. UA with trace blood and protein, 11 WBC but no signs of infection. Lactate was wnl on ___. =============== CHRONIC ISSUES: =============== # HCV # HBV # Transaminitis Has a nonocclusive thrombus on RUQUS. Continued tenofovir for now given possible flare of hepatitis if stopped. # Cancer associated pain Received Tylenol up to 2g daily and oxy 5mg prn for pain. # HTN d/c'ed home amlodipine, losartan due to soft pressures (SBP ~100s). # GERD Continued home omeprazole for discomfort from acid reflux. #CODE: DNR/DNI (as of ___ - MOLST in chart). #CONTACT: ___ Relationship: son Phone number: ___ TRANSITIONAL ISSUES =================== []FYI: Pt is DNR/DNI, MOLST form in chart (signed ___. []Holding home lenvatinib (Onc) for the time being. Can consider restarting if within goals of care/offers symptomatic support. []Continued Viread (tenofovir) due to concern for possible hepatitis flare if stopped. Can discontinue if not within GOC. []Consider using dark towels/wipes. Suspect he will have ongoing bleeding from rectum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Lenvima (lenvatinib) 12 mg oral DAILY 4. Omeprazole 20 mg PO DAILY 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Propranolol 20 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Losartan Potassium 100 mg PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN acid reflux 2. Furosemide 20 mg PO DAILY 3. Lactulose 15 mL PO DAILY:PRN Constipation - Second Line 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. Senna 8.6 mg PO DAILY 7. Spironolactone 50 mg PO DAILY cirrhosis c/b ascites 8. Docusate Sodium 100 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 11. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 12. HELD- Lenvima (lenvatinib) 12 mg oral DAILY This medication was held. Do not restart Lenvima until you discuss with Dr ___ ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hematochezia Internal hemmorhoids Acute on chronic anemia Colon cancer Recent diagnosis pulmonary embolism Decompensated cirrhosis Coagulopathy Hepatocellular carcinoma Hemoptysis Elevated lactate Transaminitis Secondary Diagnoses: Hypertension Acid reflux History of Hep B, Hep C Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital for blood in your stools. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did a colonoscopy (taking a look inside your gut to figure out where the bleeding was coming from). The bleeding is due to hemorrhoids (dilated veins in your rectum). Your bleeding improved, but you still had some bleeding when you left. -We had our Palliative Care doctors ___. They helped arrange home with hospice services. Hospice is type of care you receive to make people comfortable as they near the end of their lives. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Please call hospice if you have any questions or concerns We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "K648", "I81", "C7800", "R042", "C189", "C187", "Z66", "I10", "E785", "K7460", "Z8505", "K219", "F17210", "Z86711", "Z515", "G893", "K5520", "T45515A" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: bright red blood in stools Major Surgical or Invasive Procedure: None. History of Present Illness: PCP: [MASKED]. [MASKED] -- [MASKED] ([MASKED]) CC: [MASKED] bleeding HISTORY OF PRESENT ILLNESS: =========================== Mr. [MASKED] is a [MASKED] with history of HTN, HLD, CRC s/p sigmoidectomy/FOLFOX ([MASKED]) and HCV + HBV c/b cirrhosis and HCC s/p resection/adjuvant chemo c/b recurrence and lung mets ([MASKED]) who presents with BRBPR in setting of anticoagulation for recent PE. History taken from son and chart. Mr. [MASKED] was discharged from [MASKED] [MASKED] for hospitalization where he was found to have metastatic HCC to the lung as well as new PE. He was discharged on 3 days of Lovenox, with instructions to switch to apixaban on [MASKED]. Son reports that patient only just filled the apixaban script prior to presenting to the ED on [MASKED] and has not been taking any anticoagulation since his Lovenox ran out on [MASKED]. By report, the patient has been experiencing rectal urgency and tenesmus for the last ~20 days. 3 days PTA, he began noticing blood in the toilet bowl. Since then, he has been having [MASKED] very small bowel movements per day, all with bright red blood. He denies pain with defecation, lightheadedness or presyncope, and his appetite is minimal at baseline. He endorses 2 episodes of non-bloody emesis- toward the end of his second episode he had streaks of emesis but no frank blood. He denies generalized itchiness and his son reports he does not look more jaundiced than usual. He reports ~10 days of mild hemoptysis that he attributed to his lung met, but he has not had any hemoptysis since the rectal bleeding began. Yesterday morning (in the ED) he began experiencing [MASKED] right frontal headaches that are non-positional and do not change withneck flexion, as well as mild lower abdominal/suprapubic pain. He had a paracentesis [MASKED] with removal 3.4L, negative for SBP - PMNs 60. Since then his son reports that his abdominal swelling has slowly re-accumulated but is not as tense or distended as it was prior to the paracentesis. He does not get regular paracenteses. In the ED, vitals were: T 96.7 HR 76 BP 113/77 RR 18 O2 Sat 98% RA Exam: No acute distress RRR, no m/r/g Lungs CTAB Distended abdomen w/ ascites, nontender No spider angiomas/nail changes No asterixis Labs: CBC: WBC 3.4, Hb 11.6 from nadir of 10.8, Plt 89 BMP: Na 137, K 4.9, Cl 110, HCO3 19, BUN 14, Cr 1.0, Ca 8.2, Mg 2.4, Ph 1.9 LFT: ALT 176, AST 685, AP 238, Tbili 7.7. Alb 2.5 Lactate 2.4 UA with 2+ urobilinogen, otherwie unremarkable UCx pending Studies: Colonoscopy [MASKED]: internal hemorrhoids, no active bleeding. Also showed small angiodysplasia and submucosal mass RUQUS [MASKED] 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. He was given: For GIB: 2L LR, CTX 1g IV (ppx) For BP: home amlodipine He also got fleet enema in preparation for his colonoscopy. On arrival to the floor, patient reports that he has [MASKED] headache which is improved compared to the ED. He also reports a little abdominal discomfort and fullness. He feels cold which is his baseline. He does not have any dizziness or lightheadedness. He does not have any blurred vision, palpitations, or shortness of breath. He denies any fever, chills or sweats. No abdominal pain. His last bowel movement was [MASKED] in the evening. He has not had anything to drink for most of the day. Past Medical History: HCV HBV Cirrhosis HCC s/p resection ([MASKED]) and RFA ([MASKED]) c/b recurrence and lung mets ([MASKED]) Colon CA stage 3B KRAS+ s/p sigmoid colectomy and adjuvant chemo ([MASKED]) Acute cholecystitis s/p CCY [MASKED] HTN Dyslipidemia GERD Hearing loss Social History: [MASKED] Family History: No pertinent family history Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 98.2, HR 75, BP 120/79, RR 18, SpO2 97% RA GENERAL: Alert and interactive. In no acute distress. [MASKED]. HEENT: PERRL, EOMI. MMM. Sclera and soft palate are icteric. Bilateral hearing aids in place. Wearing glasses. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, no organomegaly. Abdomen is visibly distended with shifting dullness to percussion. No tenderness to deep palpation in [MASKED] quadrants or suprapubic EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Diffusely jaundiced with some palmar erythema, no spider angiomata. Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3 but confused about longterm history. Defers to son. Moving all 4 limbs spontaneously. CN2-12 intact.Normal sensation. No asterixis DISCHARGE PHYSCIAL EXAM ======================== 24 HR Data (last updated [MASKED] @ 024) Temp: 98.2 (Tm 98.2), BP: 109/62 (102-115/62-75), HR: 78 (78-82), RR: 18 ([MASKED]), O2 sat: 95% (95-98), O2 delivery: RA GENERAL: NAD, [MASKED]. Son at bedside. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA. CTAB. ABDOMEN: well-healed scar in RUQ from prior procedure. Firm particularly in RUQ, mildly distended, no ttp. EXTREMITIES: Trace [MASKED]. SKIN: Diffusely jaundiced in lower extremities. NEUROLOGIC: Awake, not oriented to time (per son, this is baseline). No focal neurologic deficits. Normal gait. Pertinent Results: ADMISSION LABS: [MASKED] 06:15PM BLOOD WBC-4.6 RBC-4.17* Hgb-13.1* Hct-39.0* MCV-94 MCH-31.4 MCHC-33.6 RDW-30.5* RDWSD-102.2* Plt [MASKED] [MASKED] 06:15PM BLOOD Neuts-59.8 Lymphs-17.2* Monos-14.9* Eos-3.4 Baso-1.5* Im [MASKED] AbsNeut-2.77 AbsLymp-0.80* AbsMono-0.69 AbsEos-0.16 AbsBaso-0.[MASKED] 06:15PM BLOOD [MASKED] PTT-38.1* [MASKED] [MASKED] 06:15PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-137 K-4.9 Cl-105 HCO3-21* AnGap-11 [MASKED] 06:15PM BLOOD ALT-176* AST-685* AlkPhos-238* TotBili-7.7* [MASKED] 07:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.8 [MASKED] 06:27AM BLOOD calTIBC-122* Ferritn-397 TRF-94* [MASKED] 06:27AM BLOOD IgM HAV-NEG [MASKED] 07:45AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT [MASKED] 08:06AM BLOOD pO2-70* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Comment-GREEN TOP [MASKED] 06:24PM BLOOD Lactate-2.8* [MASKED] 12:13AM BLOOD Lactate-3.3* [MASKED] 03:04AM BLOOD Lactate-3.0* [MASKED] 03:25PM BLOOD Lactate-2.4* [MASKED] 08:06AM BLOOD Lactate-2.0 DISCHARGE LABS: [MASKED] 07:35AM BLOOD WBC-5.1 RBC-3.01* Hgb-9.8* Hct-29.2* MCV-97 MCH-32.6* MCHC-33.6 RDW-32.1* RDWSD-110.6* Plt Ct-65* [MASKED] 07:35AM BLOOD Glucose-108* UreaN-17 Creat-1.1 Na-141 K-4.1 Cl-112* HCO3-21* AnGap-8* MICRO: [MASKED] 3:16 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] 3:16 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. REPORTS: [MASKED] PERITONEAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS [MASKED] LIVER U/S: 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. [MASKED] COLONOSCOPY: POLYPS IN COLON, ANGIOECTASIAS IN COLON, INTERNAL HEMMORHOIDS, PREVIOUS SURGERY IN COLON. Brief Hospital Course: Mr. [MASKED] is a [MASKED] y.o. male patient with HBC, HCV cirrhosis c/b HCC with newly diagnosed lung mets ([MASKED]), s/p resection [MASKED], RFA to segment VIII lesions, RFA to recurrent lesion [MASKED], adenocarcinoma of colon (s/p sigmoid colectomy and FOLFOX [MASKED], and non-occlusive L portal vein thrombus who was recently admitted for acute RLL subsegmental PE from [MASKED] and re-admitted on [MASKED] for BRBPR likely [MASKED] internal hemorrhoids. Given metastatic HCC, new lesion c/f recurrence of colon adenocarcinoma, all c/b acute PE, Palliative Care was consulted and family decision was made to make pt DNR/DNI with plan to transition to home with hospice. ACUTE ISSUES: ============= # Rectal bleeding # Normocytic anemia # History of colon cancer s/p sigmoid resection in [MASKED] in [MASKED] + FOLFOX: Stage IIIB, T3N1cM0 [MASKED] # New 2cm lesion in neo-sigmoid colon [MASKED] CT abd) Patient presenting with BRBPR likely [MASKED] internal hemorrhoids though possibly also rectal varices given cirrhosis. [MASKED] colonoscopy notable for internal hemorrhoids, non-bleeding angioectasias in colon. Of note patient also restarted apixaban for cancer-associated PE, but did not take this due to inability to fill the medication. He was initially started on hep gtt and apixaban for recent diagnosis of PE, but this was discontinued on [MASKED] given ongoing BRBPR. He continued to have ongoing BRBPR, but reported this decreased compared to admission. He was hemodynamically stable and did not require any transfusions during his hospitalization. #Recent dx PE We discussed the risks of not angicoagulating, to which pt's son agreed to stopping anticoagulation given ongoing BRBPR. # Decompensated cirrhosis c/b coagulopathy # [MASKED] s/p liver resection in [MASKED] [MASKED] # History of HBC and HCV Patient has a long h/o cirrhosis [MASKED] viral hepatitis (HCV and HBV) and c/b HCC. Has historically been well-compensated but presents now in decompensation i/s/o hyperbilirubinemia, elevated LFTs and tumor markers, and coagulopathy. He has a h/o ascites with last outpatient paracentesis on [MASKED], with removal of 3.4L; studies negative for SBP. Repeat para on [MASKED] removed ~2L fluid while inpatient and studies neg for SBP. He was started on PO Lasix 20mg qd + PO spironolactone 50mg qd ([MASKED]) for abd distension discomfort. #GOC After discussion w/ Pall Care on [MASKED], decision was made to make pt DNR/DNI and plan for home with hospice. He continues to have repeated episodes of BRBPR, though appears to have improved after stopping apixaban for PE. They prefer to have a hospice agency that works with [MASKED] pts. DNR/DNI as of [MASKED]. MOLST in chart. #Hemoptysis Presented with blood-tinged sputum during this admission, reportedly had this in the past as well. Likely [MASKED] re-starting AC, though improving. Predisposed to bleeding given pt has cirrhosis, coagulopathy. Per pt, this resolved. # Elevated lactate: 2.8 on arrival increased to 3.0 and then back down to 2.4 with some fluids. UA with trace blood and protein, 11 WBC but no signs of infection. Lactate was wnl on [MASKED]. =============== CHRONIC ISSUES: =============== # HCV # HBV # Transaminitis Has a nonocclusive thrombus on RUQUS. Continued tenofovir for now given possible flare of hepatitis if stopped. # Cancer associated pain Received Tylenol up to 2g daily and oxy 5mg prn for pain. # HTN d/c'ed home amlodipine, losartan due to soft pressures (SBP ~100s). # GERD Continued home omeprazole for discomfort from acid reflux. #CODE: DNR/DNI (as of [MASKED] - MOLST in chart). #CONTACT: [MASKED] Relationship: son Phone number: [MASKED] TRANSITIONAL ISSUES =================== []FYI: Pt is DNR/DNI, MOLST form in chart (signed [MASKED]. []Holding home lenvatinib (Onc) for the time being. Can consider restarting if within goals of care/offers symptomatic support. []Continued Viread (tenofovir) due to concern for possible hepatitis flare if stopped. Can discontinue if not within GOC. []Consider using dark towels/wipes. Suspect he will have ongoing bleeding from rectum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Lenvima (lenvatinib) 12 mg oral DAILY 4. Omeprazole 20 mg PO DAILY 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Propranolol 20 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Losartan Potassium 100 mg PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN acid reflux 2. Furosemide 20 mg PO DAILY 3. Lactulose 15 mL PO DAILY:PRN Constipation - Second Line 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. Senna 8.6 mg PO DAILY 7. Spironolactone 50 mg PO DAILY cirrhosis c/b ascites 8. Docusate Sodium 100 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 11. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 12. HELD- Lenvima (lenvatinib) 12 mg oral DAILY This medication was held. Do not restart Lenvima until you discuss with Dr [MASKED] [MASKED] Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Hematochezia Internal hemmorhoids Acute on chronic anemia Colon cancer Recent diagnosis pulmonary embolism Decompensated cirrhosis Coagulopathy Hepatocellular carcinoma Hemoptysis Elevated lactate Transaminitis Secondary Diagnoses: Hypertension Acid reflux History of Hep B, Hep C Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You came to the hospital for blood in your stools. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did a colonoscopy (taking a look inside your gut to figure out where the bleeding was coming from). The bleeding is due to hemorrhoids (dilated veins in your rectum). Your bleeding improved, but you still had some bleeding when you left. -We had our Palliative Care doctors [MASKED]. They helped arrange home with hospice services. Hospice is type of care you receive to make people comfortable as they near the end of their lives. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Please call hospice if you have any questions or concerns We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "Z66", "I10", "E785", "K219", "F17210", "Z515" ]
[ "K648: Other hemorrhoids", "I81: Portal vein thrombosis", "C7800: Secondary malignant neoplasm of unspecified lung", "R042: Hemoptysis", "C189: Malignant neoplasm of colon, unspecified", "C187: Malignant neoplasm of sigmoid colon", "Z66: Do not resuscitate", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K7460: Unspecified cirrhosis of liver", "Z8505: Personal history of malignant neoplasm of liver", "K219: Gastro-esophageal reflux disease without esophagitis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z86711: Personal history of pulmonary embolism", "Z515: Encounter for palliative care", "G893: Neoplasm related pain (acute) (chronic)", "K5520: Angiodysplasia of colon without hemorrhage", "T45515A: Adverse effect of anticoagulants, initial encounter" ]
10,052,992
24,411,782
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: new metastatic lesions Major Surgical or Invasive Procedure: ___ guided lung biopsy History of Present Illness: ___ PMH HCC (s/p liver resection + RFA) as well as colon cancer (s/p resection + adjuvant FOLFOX), presents today with new metastatic lesions on imaging + acute PE As per review of ___ clinic notes, pt last seen in ___ when he was felt to be in remission for colon cancer but AFP was rising. Subsequent CT ___ was without evidence of new or recurrent disease. On ___ patient had Colonoscopy without any e/o malignancy. Today, patient had CT scans which revealed new liver lesions which appeared more c/w colorectal metastases, and was also found to have apply core lesion in neo-sigmoid colon c/f malignancy. CT chest revealed RLL PE, numerous b/l lung nodules c/w metastatic disease, as well as new thyroid nodules. In light of new malignant lesions, patient referred to ED by outpatient oncologist for expedited w/u including biopsy to determine if lesions are due to HCC or colon cancer recurrence. Pt reports that he has some shortness of breath, but is without any chest pain or pleurisy. He noted that he feels wheezy, denied any cough, fever or chills. He noted that he has intermittent constipation and is only been passing small bowel movements which she is concerned about. Noted that he is tolerating oral intake and is voiding without difficulty. He noted that he is concerned about the cancerous lesions and is hopeful that there is a treatment In the ED, initial vitals: 96.9 59 129/80 16 100% RA. Hgb 12.4 plt 109, WBC wnl, CHEM w/ HCO3 20, Lactate 2.3, INR 1.6 CTH: No acute intracranial process. Mild small vessel disease no definite intracranial mets. Patient was admitted for expedited workup with biopsy Past Medical History: PAST ONCOLOGIC HISTORY: Hepatocellular carcinoma in the setting of HCV, HBV, and possible alcoholic cirrhosis - ___ Resection of a primary HCC by report - ___ Presented with worsening abdominal pain. - ___ EGD revealed grade I varices and a gastric ulcer - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since ___, however now meets OPTN 5a criteria for HCC. New 1.2 x 1 cm arterially hyperenhancing segment VIII lesion does not meet strict OPTN-5 criteria but is suspicious for HCC. - ___ RFA of the larger segment VIII lesion - ___ MR liver showed full treatment of the segment VIII lesion, stable segment VII lesion - ___ CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - ___ PET ___ - ___ CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - ___ RFA to his recurrent HCC - ___ CT abdomen showed a 2.2 cm segment VI HCC by OPTN - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ Presented with BRBPR - ___ Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. - ___ Underwent sigmoid colectomy and CCY. - ___ C1D1 FOLFOX6 - ___ C2D1 modified FOLFOX (no bolus ___, LV 200 mg/m2, oxaliplatin 65 mg/m2) + Neulasta delayed and reduced for cytopenias and liver injury - ___ dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection - ___ Holding further chemo for past toxicity - ___ CT torso ___ - ___ MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since ___, however now meets OPTN 5a criteria for HCC. - ___ Colonoscopy with poor prep, at least one adenoma identified and removed - ___ CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - ___ PET ___ - ___ CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - ___ Colonoscopy showed 2 polyps, GI recommended repeat in ___ years - ___ CT abdomen showed a 2.2 cm segment VI HCC by OPTN criteria, no metastatic disease Social History: ___ Family History: Non contributory Physical Exam: GENERAL: Lying in bed, appears comfortable, son at bedside EYES: Pupils equally round, anicteric HEENT: Oropharynx clear, moist mucous membranes NECK: Neck supple, normal range of motion LUNGS: Wheezing plus rhonchi left mid to lower lobe, respiratory rate was normal, patient without increased work of breathing. RLL biopsy site dressing c/d/i CV: Regular rate and rhythm, no murmurs rubs or gallops ABD: Soft, distended, resonant to percussion, nontender, no rebound or guarding GENITOURINARY: No Foley EXT: Decreased muscle bulk, moving all extremities spontaneously SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech ACCESS: Peripheral IV Pertinent Results: ___ 01:28PM CREAT-1.0 ___ 06:35PM WBC-4.3 RBC-4.10* HGB-12.4* HCT-35.4* MCV-86 MCH-30.2 MCHC-35.0 RDW-23.8* RDWSD-72.2* ___ 06:46PM ___ PTT-41.9* ___ ___ 06:50PM LACTATE-2.3* ___ 08:05AM BLOOD WBC-7.7 RBC-4.17* Hgb-12.3* Hct-36.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-25.2* RDWSD-75.1* Plt Ct-86* ___ 03:00AM BLOOD ___ PTT-63.0* ___ ___ 08:05AM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-144 K-4.1 Cl-111* HCO3-19* AnGap-14 ___ 03:00AM BLOOD ALT-80* AST-370* AlkPhos-185* TotBili-3.1* ___ 08:05AM BLOOD Calcium-7.9* Phos-4.3 Mg-1.6 ___ 09:15AM BLOOD CEA-3.9 ___ CT A/P IMPRESSION: 1. New OPTN 5 B lesions in segment II, V and VI. 2. A new enhancing mass in segment VI is not hyperenhancing on the arterial phase, and maintains persistent enhancement, with an appearance more characteristic of colorectal metastasis than hepatocellular carcinoma by imaging. 3. Re-demonstrated treatment cavities in segment VII and VIII, without evidence of local recurrence. Treatment cavity in segment VI is re-demonstrated, with some enhancement but no definite washout and overall the appearance is similar to prior. Continued attention on follow-up is recommended. 4. Nonocclusive thrombosis in the left portal vein. 5. Stable splenomegaly, with new moderate volume ascites. 6. New 2 cm long apple-core lesion in the neo sigmoid colon is concerning for malignancy. Recommend correlation with direct visualization. 7. Please refer to the separately dictated CT chest report from the same date for a description of thoracic findings. Chest CT IMPRESSION: 1. Right lower lobe subsegmental pulmonary arterial filling defects compatible with recent pulmonary emboli, new since the prior study. 2. Numerous bilateral lung nodules, new since, are likely metastases. 3. Bilateral hypodense nodules in the thyroid measure up to 1.3 cm on the right. Further evaluation with thyroid ultrasound is recommended if clinically appropriate. 4. Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. CT head IMPRESSION: No acute intracranial process. Mild small vessel disease. No definite evidence for intracranial metastasis. There is further concern, an MRI may be performed to further assess. Colonoscopy -Colonic mucosa appeared normal. Prep was fair. The sigmoid colon was thoroughly evaluated with the therapeutic EGD scope and then with a standard EGD scope. No mass was seen. A circumferentially thickened fold was seen in the distal sigmoid at the site of the anastomosis but otherwise appeared normal. The anastomosis was seen on tretroflexion and appeared normal. The thickened sigmoid fold possibly may have caused the CT findings. The lumen was not obstructing and was widely patent and hence a colonic stent was not placed/indicated Brief Hospital Course: ___ PMH HCC (s/p liver resection + RFA) as well as colon cancer (s/p resection + adjuvant FOLFOX), presents today with new metastatic lesions on imaging + acute PE. Also with significant obstructive bowel sx s/p ___. He was started on heparin drip for PE. ___ guided biopsy of lung was performed and results pending. He underwent ___ which did not show an obstructive lesion, after which his obstructive bowel symptoms improved. He is resumed on lovenox for PE and is stable for discharge with onc follow up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. amLODIPine 10 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 80 mg subq every twelve (12) hours Disp #*14 Syringe Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by mouth daily Refills:*0 3. Senna 17.2 mg PO DAILY RX *sennosides 8.6 mg 2 tab by mouth daily Disp #*28 Tablet Refills:*0 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 5. Omeprazole 20 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Metastatic cancer of unknown primary history of liver cancer history of colon cancer Acute pulmonary embolism Discharge Condition: fair A/Ox3 self-ambulatory without assist Discharge Instructions: Dear ___ were admitted to the hospital after your oncologist found new cancer lesions in your colon, liver, thyroid, and lungs. Your lung lesion is biopsied and the results are pending. ___ also were found to have a pulmonary embolism, and need to take a blood thinner shot twice a day. Followup Instructions: ___
[ "C7801", "I2699", "E440", "B1910", "C787", "B181", "D649", "D696", "I10", "E042", "J45909", "F17210", "B182", "Z6828", "Z8505", "C7802", "Z86718", "Z7901", "Z85038", "Z9221" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: new metastatic lesions Major Surgical or Invasive Procedure: [MASKED] guided lung biopsy History of Present Illness: [MASKED] PMH HCC (s/p liver resection + RFA) as well as colon cancer (s/p resection + adjuvant FOLFOX), presents today with new metastatic lesions on imaging + acute PE As per review of [MASKED] clinic notes, pt last seen in [MASKED] when he was felt to be in remission for colon cancer but AFP was rising. Subsequent CT [MASKED] was without evidence of new or recurrent disease. On [MASKED] patient had Colonoscopy without any e/o malignancy. Today, patient had CT scans which revealed new liver lesions which appeared more c/w colorectal metastases, and was also found to have apply core lesion in neo-sigmoid colon c/f malignancy. CT chest revealed RLL PE, numerous b/l lung nodules c/w metastatic disease, as well as new thyroid nodules. In light of new malignant lesions, patient referred to ED by outpatient oncologist for expedited w/u including biopsy to determine if lesions are due to HCC or colon cancer recurrence. Pt reports that he has some shortness of breath, but is without any chest pain or pleurisy. He noted that he feels wheezy, denied any cough, fever or chills. He noted that he has intermittent constipation and is only been passing small bowel movements which she is concerned about. Noted that he is tolerating oral intake and is voiding without difficulty. He noted that he is concerned about the cancerous lesions and is hopeful that there is a treatment In the ED, initial vitals: 96.9 59 129/80 16 100% RA. Hgb 12.4 plt 109, WBC wnl, CHEM w/ HCO3 20, Lactate 2.3, INR 1.6 CTH: No acute intracranial process. Mild small vessel disease no definite intracranial mets. Patient was admitted for expedited workup with biopsy Past Medical History: PAST ONCOLOGIC HISTORY: Hepatocellular carcinoma in the setting of HCV, HBV, and possible alcoholic cirrhosis - [MASKED] Resection of a primary HCC by report - [MASKED] Presented with worsening abdominal pain. - [MASKED] EGD revealed grade I varices and a gastric ulcer - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since [MASKED], however now meets OPTN 5a criteria for HCC. New 1.2 x 1 cm arterially hyperenhancing segment VIII lesion does not meet strict OPTN-5 criteria but is suspicious for HCC. - [MASKED] RFA of the larger segment VIII lesion - [MASKED] MR liver showed full treatment of the segment VIII lesion, stable segment VII lesion - [MASKED] CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - [MASKED] PET [MASKED] - [MASKED] CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - [MASKED] RFA to his recurrent HCC - [MASKED] CT abdomen showed a 2.2 cm segment VI HCC by OPTN - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] Presented with BRBPR - [MASKED] Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. - [MASKED] Underwent sigmoid colectomy and CCY. - [MASKED] C1D1 FOLFOX6 - [MASKED] C2D1 modified FOLFOX (no bolus [MASKED], LV 200 mg/m2, oxaliplatin 65 mg/m2) + Neulasta delayed and reduced for cytopenias and liver injury - [MASKED] dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection - [MASKED] Holding further chemo for past toxicity - [MASKED] CT torso [MASKED] - [MASKED] MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since [MASKED], however now meets OPTN 5a criteria for HCC. - [MASKED] Colonoscopy with poor prep, at least one adenoma identified and removed - [MASKED] CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - [MASKED] PET [MASKED] - [MASKED] CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - [MASKED] Colonoscopy showed 2 polyps, GI recommended repeat in [MASKED] years - [MASKED] CT abdomen showed a 2.2 cm segment VI HCC by OPTN criteria, no metastatic disease Social History: [MASKED] Family History: Non contributory Physical Exam: GENERAL: Lying in bed, appears comfortable, son at bedside EYES: Pupils equally round, anicteric HEENT: Oropharynx clear, moist mucous membranes NECK: Neck supple, normal range of motion LUNGS: Wheezing plus rhonchi left mid to lower lobe, respiratory rate was normal, patient without increased work of breathing. RLL biopsy site dressing c/d/i CV: Regular rate and rhythm, no murmurs rubs or gallops ABD: Soft, distended, resonant to percussion, nontender, no rebound or guarding GENITOURINARY: No Foley EXT: Decreased muscle bulk, moving all extremities spontaneously SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech ACCESS: Peripheral IV Pertinent Results: [MASKED] 01:28PM CREAT-1.0 [MASKED] 06:35PM WBC-4.3 RBC-4.10* HGB-12.4* HCT-35.4* MCV-86 MCH-30.2 MCHC-35.0 RDW-23.8* RDWSD-72.2* [MASKED] 06:46PM [MASKED] PTT-41.9* [MASKED] [MASKED] 06:50PM LACTATE-2.3* [MASKED] 08:05AM BLOOD WBC-7.7 RBC-4.17* Hgb-12.3* Hct-36.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-25.2* RDWSD-75.1* Plt Ct-86* [MASKED] 03:00AM BLOOD [MASKED] PTT-63.0* [MASKED] [MASKED] 08:05AM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-144 K-4.1 Cl-111* HCO3-19* AnGap-14 [MASKED] 03:00AM BLOOD ALT-80* AST-370* AlkPhos-185* TotBili-3.1* [MASKED] 08:05AM BLOOD Calcium-7.9* Phos-4.3 Mg-1.6 [MASKED] 09:15AM BLOOD CEA-3.9 [MASKED] CT A/P IMPRESSION: 1. New OPTN 5 B lesions in segment II, V and VI. 2. A new enhancing mass in segment VI is not hyperenhancing on the arterial phase, and maintains persistent enhancement, with an appearance more characteristic of colorectal metastasis than hepatocellular carcinoma by imaging. 3. Re-demonstrated treatment cavities in segment VII and VIII, without evidence of local recurrence. Treatment cavity in segment VI is re-demonstrated, with some enhancement but no definite washout and overall the appearance is similar to prior. Continued attention on follow-up is recommended. 4. Nonocclusive thrombosis in the left portal vein. 5. Stable splenomegaly, with new moderate volume ascites. 6. New 2 cm long apple-core lesion in the neo sigmoid colon is concerning for malignancy. Recommend correlation with direct visualization. 7. Please refer to the separately dictated CT chest report from the same date for a description of thoracic findings. Chest CT IMPRESSION: 1. Right lower lobe subsegmental pulmonary arterial filling defects compatible with recent pulmonary emboli, new since the prior study. 2. Numerous bilateral lung nodules, new since, are likely metastases. 3. Bilateral hypodense nodules in the thyroid measure up to 1.3 cm on the right. Further evaluation with thyroid ultrasound is recommended if clinically appropriate. 4. Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. CT head IMPRESSION: No acute intracranial process. Mild small vessel disease. No definite evidence for intracranial metastasis. There is further concern, an MRI may be performed to further assess. Colonoscopy -Colonic mucosa appeared normal. Prep was fair. The sigmoid colon was thoroughly evaluated with the therapeutic EGD scope and then with a standard EGD scope. No mass was seen. A circumferentially thickened fold was seen in the distal sigmoid at the site of the anastomosis but otherwise appeared normal. The anastomosis was seen on tretroflexion and appeared normal. The thickened sigmoid fold possibly may have caused the CT findings. The lumen was not obstructing and was widely patent and hence a colonic stent was not placed/indicated Brief Hospital Course: [MASKED] PMH HCC (s/p liver resection + RFA) as well as colon cancer (s/p resection + adjuvant FOLFOX), presents today with new metastatic lesions on imaging + acute PE. Also with significant obstructive bowel sx s/p [MASKED]. He was started on heparin drip for PE. [MASKED] guided biopsy of lung was performed and results pending. He underwent [MASKED] which did not show an obstructive lesion, after which his obstructive bowel symptoms improved. He is resumed on lovenox for PE and is stable for discharge with onc follow up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. amLODIPine 10 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 80 mg subq every twelve (12) hours Disp #*14 Syringe Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by mouth daily Refills:*0 3. Senna 17.2 mg PO DAILY RX *sennosides 8.6 mg 2 tab by mouth daily Disp #*28 Tablet Refills:*0 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 5. Omeprazole 20 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Metastatic cancer of unknown primary history of liver cancer history of colon cancer Acute pulmonary embolism Discharge Condition: fair A/Ox3 self-ambulatory without assist Discharge Instructions: Dear [MASKED] were admitted to the hospital after your oncologist found new cancer lesions in your colon, liver, thyroid, and lungs. Your lung lesion is biopsied and the results are pending. [MASKED] also were found to have a pulmonary embolism, and need to take a blood thinner shot twice a day. Followup Instructions: [MASKED]
[]
[ "D649", "D696", "I10", "J45909", "F17210", "Z86718", "Z7901" ]
[ "C7801: Secondary malignant neoplasm of right lung", "I2699: Other pulmonary embolism without acute cor pulmonale", "E440: Moderate protein-calorie malnutrition", "B1910: Unspecified viral hepatitis B without hepatic coma", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "B181: Chronic viral hepatitis B without delta-agent", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "E042: Nontoxic multinodular goiter", "J45909: Unspecified asthma, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "B182: Chronic viral hepatitis C", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "Z8505: Personal history of malignant neoplasm of liver", "C7802: Secondary malignant neoplasm of left lung", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z9221: Personal history of antineoplastic chemotherapy" ]
10,052,992
26,248,042
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dizziness, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with hx of Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who presented this evening with CP and 'dizzyness' x1 week. The patient states that he has had CP over the past week intermittently but that it has worsened and become constant over the past few days. No fevers, chronic cough, no palpitations, no vomiting, no diarrhea. Describes anorexia which has been ongoing associated with his cirrhosis. Positional lightheadedness. The patient has undergone a number of medication changes recently. He was recently (___) started on spironolactone for ascites and hypokalemia. On ___ the patient was scheduled for RFA ablation. Prior to the procedure he was noted to be in rapid afib (new for him). It appears the procedure was aborted and the patient was managed with IV metoprolol then sent home on PO metoprolol. His amlodipine was stopped. Felt dizzy after returning home and stopped taking spironolactone. In the ED, the patient was evaluated for ACS and PE. CTPE was without evidence of PE. ECG showed NSR without ischemic change and trop was flat. K+ noted to be low at 2.7. Also found to be orthostatic. Started on K+ repletion. On arrival to the floor, patient states (through son who speaks ___ that he feels a bit better. Chest pain mostly resolved. Still some dizziness, especially when sitting up. Past Medical History: ONCOLOGIC HISTORY: Colon cancer stage IIIB (T3 N1c M0) KRAS w/t MSI stable by ___ - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ Presented with BRBPR - ___ Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. Biopsies revealed adenocarcinoma. CT torso that day showed perforated cholecystitis, a sigmoid colon mass, a 1.5 cm hepatic lesion suspicious for HCC, an adrenal adenoma, and possible mesenteric vasculitis. - ___ Underwent sigmoid colectomy and CCY. Colectomy revealed low grade adenocarcinoma, pT2 pN1c with 15 LNs sampled and negative for disease but with mesenteric deposits of disease (N1c). Margins widely negative, LVI present, PNI present, infiltrating lymphocytes present. KRAS w/t and MSI stable by IHC. - ___ C1D1 FOLFOX6 - ___ C1D15 mFOLFOX 6 (removed ___ bolus and added neulasta for neutropenia and thrombocytopenia) PAST MEDICAL HISTORY 1. Hepatitis B. 2. Hepatitis C. 3. History of hepatitis E infection. 4. Hepatocellular carcinoma (presumed) diagnosed in ___, status post resection in ___ in ___. Presumed hepatocellular carcinoma (new, NOT recurrence) in segment VII, discovered in ___ MRI 5. Cirrhosis complicated by upper GI bleeding from portal hypertensive gastropathy and thrombocytopenia. 6. Hypertension. 7. Hyperlipidemia. 8. GERD. 9. Hearing loss. 10. Sigmoid adenocarcinoma 11. Acute cholecystitis complicated by perforation and subhepatic abscess Social History: ___ Family History: Non contributory Physical Exam: Admission Exam ================ VS - 98.5 172 / 98 69 16 98 RA General - Lying in bed, NAD HEENT - MMM, OP clear CV - RRR, S1 and S2, no m/r/g Lung - CTAB, no w/r/r Abd - Soft, NT/ND Ext - No c/c/e Skin - No rash Neuro - Alert and oriented. CN II-XII intact. Strength ___ throughout. Smile symmetric. Discharge Exam ============== VS: 98.1 PO 163 / 82 R Lying 70 18 97 Ra GEN: NAD, cachexic appearing elderly male HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___ sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities. sensation intact to LT, gait deferred this morning. Pertinent Results: Admission Labs =============== ___ 06:50PM BLOOD WBC-4.8 RBC-3.59* Hgb-12.1* Hct-35.0* MCV-98 MCH-33.7* MCHC-34.6 RDW-16.0* RDWSD-57.0* Plt Ct-64* ___ 06:50PM BLOOD Neuts-55.7 ___ Monos-10.3 Eos-2.3 Baso-0.4 Im ___ AbsNeut-2.65# AbsLymp-1.47 AbsMono-0.49 AbsEos-0.11 AbsBaso-0.02 ___ 06:50PM BLOOD Plt Ct-64* ___ 06:50PM BLOOD Glucose-86 UreaN-10 Creat-0.8 Na-139 K-2.6* Cl-105 HCO3-21* AnGap-16 ___ 06:50PM BLOOD ALT-40 AST-48* AlkPhos-251* TotBili-1.9* ___ 06:50PM BLOOD proBNP-63 ___ 06:50PM BLOOD cTropnT-<0.01 ___ 12:37AM BLOOD cTropnT-<0.01 ___ 06:50PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.5* Mg-1.9 ___ 06:50PM BLOOD D-Dimer-7002* ___ 05:25PM BLOOD ___ pO2-41* pCO2-34* pH-7.43 calTCO2-23 Base XS-0 ___ 08:09PM BLOOD K-2.6* ___ 05:25PM BLOOD Lactate-2.7* Imaging ========== CXR ___ FINDINGS: Mild basilar atelectasis is seen without definite focal consolidation. There is no pleural effusion. The cardiac and mediastinal silhouettes are similar compared to scout radiograph from ___. IMPRESSION: Mild basilar atelectasis without definite focal consolidation. The cardiac silhouette is borderline to mildly enlarged. No pulmonary edema. CTA Chest ___ IMPRESSION: Subsegmental pulmonary arterial branches are not well evaluated due to respiratory motion, particularly in the lower lobes. No evidence of pulmonary embolism seen elsewhere. No acute aortic dissection. Moderate centrilobular and paraseptal emphysema is overall stable from the recent prior exam. Bibasilar atelectasis without focal consolidation or pleural effusion. Mediastinal lymph nodes are grossly stable. RUQ US ___ IMPRESSION: 1. The common bile duct is mildly dilated however may be partially explained as the patient is status postcholecystectomy. There is no intrahepatic biliary dilation. 2. A 2.6 x 2.2 cm predominantly hypoechoic lesion with central echogenicity is consistent with the RFA ablation site. 3. Main portal vein is patent with hepatopetal flow but attenuated. 4. Mild splenomegaly. Discharge Labs ================ ___ 07:25AM BLOOD WBC-3.5* RBC-3.18* Hgb-10.6* Hct-31.1* MCV-98 MCH-33.3* MCHC-34.1 RDW-15.9* RDWSD-56.6* Plt Ct-63* ___ 07:25AM BLOOD Neuts-43.9 ___ Monos-10.9 Eos-5.5 Baso-0.3 Im ___ AbsNeut-1.53* AbsLymp-1.34 AbsMono-0.38 AbsEos-0.19 AbsBaso-0.01 ___ 07:25AM BLOOD Plt Ct-63* ___ 07:25AM BLOOD ___ PTT-34.9 ___ ___ 07:25AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-138 K-3.3 Cl-106 HCO3-22 AnGap-13 ___ 07:25AM BLOOD ALT-33 AST-37 AlkPhos-197* TotBili-1.7* ___ 07:25AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.7 Mg-1.___ with Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who p/w CP and dizziness x1 week. Now found to be hypokalemic and orthostatic--most likely related to anorexia and medication changes. ACS was ruled out on admission. Patient found to be orthostatic and bradycardic, both of which were thought to be contributing to symptoms. Patient received IV fluids and electrolyte repletion with significant improvement. He was seen by nutrition and multivitamin was added. Patient was able to take adequate PO during admission. With regards to his bradycardia, patient was recently started on Metoprolol for new atrial fibrillation. On the medication his heart rate was in 40-50's. We held the medication and he remained in sinus rhythm, with rates in 50-70's. Patient discharged to home with close PCP and cardiology follow up. Transitional Issues ==================== -Patient's Metoprolol held during admission and on discharge, in setting of bradycardia and dizziness. Patient in NSR throughout admission. ___ consider resuming this medicine as outpatient. -Patient has newly diagnosed atrial fibrillation (although currently in sinus as above). CHADSVASC 3. PCP/Cardiologist should discuss risks and benefits of anticoagulation as outpatient. -Patient recently stopped taking Spironolactone. Dr. ___ will determine when/if this medication should be re-started in the outpatient setting. -Patient experienced atypical chest pain prior to admission. ACS ruled out but patient should follow up with cardiology and stress test may be considered. -Patient's QTc noted to be prolonged during admission. This should be monitored in outpatient setting. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg PO BID:PRN Constipation Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Losartan Potassium 100 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN Constipation 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. HELD- Metoprolol Succinate XL 50 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until instructed by your doctor 8. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until instructed by your doctor Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================== Orthostatic Hypotension Hypokalemia secondary to poor PO intake Secondary Diagnosis ==================== Hepatocellular carcinoma 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 pleasure caring for you at ___ ___. Why was I admitted to the hospital? -You were admitted because of dizziness and chest pain. What was done for me in the hospital? -You had tests that determined you were not having a heart attack. -We gave you IV fluids because you were dehydrated. -You were seen by a nutritionist who recommended you drink Ensure along with your meals and take multivitamin. -We stopped your Metoprolol because your heart rate was low. What should I do at home? -You should NOT take the Metoprolol until directed to do so by your doctor. -___ should follow up with a cardiologist for your chest pain. They will likely recommend a stress test to determine if you have underlying heart disease. -You should continue to eat and drink regularly at home, and consider supplementing your meals with Ensure. This will prevent you from becoming dehydrated and dizzy. -Please schedule a follow up appointment with your primary care doctor and ___ within the next ___ weeks. -Please schedule an appointment with Cardiology to discuss your chest pain and atrial fibrillation. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "I951", "E876", "C220", "I4891", "Z85038", "F17210", "R079", "B1910", "R630", "Z6827", "Z8619", "I81", "R627", "I10", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dizziness, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with hx of Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who presented this evening with CP and 'dizzyness' x1 week. The patient states that he has had CP over the past week intermittently but that it has worsened and become constant over the past few days. No fevers, chronic cough, no palpitations, no vomiting, no diarrhea. Describes anorexia which has been ongoing associated with his cirrhosis. Positional lightheadedness. The patient has undergone a number of medication changes recently. He was recently ([MASKED]) started on spironolactone for ascites and hypokalemia. On [MASKED] the patient was scheduled for RFA ablation. Prior to the procedure he was noted to be in rapid afib (new for him). It appears the procedure was aborted and the patient was managed with IV metoprolol then sent home on PO metoprolol. His amlodipine was stopped. Felt dizzy after returning home and stopped taking spironolactone. In the ED, the patient was evaluated for ACS and PE. CTPE was without evidence of PE. ECG showed NSR without ischemic change and trop was flat. K+ noted to be low at 2.7. Also found to be orthostatic. Started on K+ repletion. On arrival to the floor, patient states (through son who speaks [MASKED] that he feels a bit better. Chest pain mostly resolved. Still some dizziness, especially when sitting up. Past Medical History: ONCOLOGIC HISTORY: Colon cancer stage IIIB (T3 N1c M0) KRAS w/t MSI stable by [MASKED] - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] Presented with BRBPR - [MASKED] Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. Biopsies revealed adenocarcinoma. CT torso that day showed perforated cholecystitis, a sigmoid colon mass, a 1.5 cm hepatic lesion suspicious for HCC, an adrenal adenoma, and possible mesenteric vasculitis. - [MASKED] Underwent sigmoid colectomy and CCY. Colectomy revealed low grade adenocarcinoma, pT2 pN1c with 15 LNs sampled and negative for disease but with mesenteric deposits of disease (N1c). Margins widely negative, LVI present, PNI present, infiltrating lymphocytes present. KRAS w/t and MSI stable by IHC. - [MASKED] C1D1 FOLFOX6 - [MASKED] C1D15 mFOLFOX 6 (removed [MASKED] bolus and added neulasta for neutropenia and thrombocytopenia) PAST MEDICAL HISTORY 1. Hepatitis B. 2. Hepatitis C. 3. History of hepatitis E infection. 4. Hepatocellular carcinoma (presumed) diagnosed in [MASKED], status post resection in [MASKED] in [MASKED]. Presumed hepatocellular carcinoma (new, NOT recurrence) in segment VII, discovered in [MASKED] MRI 5. Cirrhosis complicated by upper GI bleeding from portal hypertensive gastropathy and thrombocytopenia. 6. Hypertension. 7. Hyperlipidemia. 8. GERD. 9. Hearing loss. 10. Sigmoid adenocarcinoma 11. Acute cholecystitis complicated by perforation and subhepatic abscess Social History: [MASKED] Family History: Non contributory Physical Exam: Admission Exam ================ VS - 98.5 172 / 98 69 16 98 RA General - Lying in bed, NAD HEENT - MMM, OP clear CV - RRR, S1 and S2, no m/r/g Lung - CTAB, no w/r/r Abd - Soft, NT/ND Ext - No c/c/e Skin - No rash Neuro - Alert and oriented. CN II-XII intact. Strength [MASKED] throughout. Smile symmetric. Discharge Exam ============== VS: 98.1 PO 163 / 82 R Lying 70 18 97 Ra GEN: NAD, cachexic appearing elderly male HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [MASKED] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII intact. [MASKED] strength in U/L extremities. sensation intact to LT, gait deferred this morning. Pertinent Results: Admission Labs =============== [MASKED] 06:50PM BLOOD WBC-4.8 RBC-3.59* Hgb-12.1* Hct-35.0* MCV-98 MCH-33.7* MCHC-34.6 RDW-16.0* RDWSD-57.0* Plt Ct-64* [MASKED] 06:50PM BLOOD Neuts-55.7 [MASKED] Monos-10.3 Eos-2.3 Baso-0.4 Im [MASKED] AbsNeut-2.65# AbsLymp-1.47 AbsMono-0.49 AbsEos-0.11 AbsBaso-0.02 [MASKED] 06:50PM BLOOD Plt Ct-64* [MASKED] 06:50PM BLOOD Glucose-86 UreaN-10 Creat-0.8 Na-139 K-2.6* Cl-105 HCO3-21* AnGap-16 [MASKED] 06:50PM BLOOD ALT-40 AST-48* AlkPhos-251* TotBili-1.9* [MASKED] 06:50PM BLOOD proBNP-63 [MASKED] 06:50PM BLOOD cTropnT-<0.01 [MASKED] 12:37AM BLOOD cTropnT-<0.01 [MASKED] 06:50PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.5* Mg-1.9 [MASKED] 06:50PM BLOOD D-Dimer-7002* [MASKED] 05:25PM BLOOD [MASKED] pO2-41* pCO2-34* pH-7.43 calTCO2-23 Base XS-0 [MASKED] 08:09PM BLOOD K-2.6* [MASKED] 05:25PM BLOOD Lactate-2.7* Imaging ========== CXR [MASKED] FINDINGS: Mild basilar atelectasis is seen without definite focal consolidation. There is no pleural effusion. The cardiac and mediastinal silhouettes are similar compared to scout radiograph from [MASKED]. IMPRESSION: Mild basilar atelectasis without definite focal consolidation. The cardiac silhouette is borderline to mildly enlarged. No pulmonary edema. CTA Chest [MASKED] IMPRESSION: Subsegmental pulmonary arterial branches are not well evaluated due to respiratory motion, particularly in the lower lobes. No evidence of pulmonary embolism seen elsewhere. No acute aortic dissection. Moderate centrilobular and paraseptal emphysema is overall stable from the recent prior exam. Bibasilar atelectasis without focal consolidation or pleural effusion. Mediastinal lymph nodes are grossly stable. RUQ US [MASKED] IMPRESSION: 1. The common bile duct is mildly dilated however may be partially explained as the patient is status postcholecystectomy. There is no intrahepatic biliary dilation. 2. A 2.6 x 2.2 cm predominantly hypoechoic lesion with central echogenicity is consistent with the RFA ablation site. 3. Main portal vein is patent with hepatopetal flow but attenuated. 4. Mild splenomegaly. Discharge Labs ================ [MASKED] 07:25AM BLOOD WBC-3.5* RBC-3.18* Hgb-10.6* Hct-31.1* MCV-98 MCH-33.3* MCHC-34.1 RDW-15.9* RDWSD-56.6* Plt Ct-63* [MASKED] 07:25AM BLOOD Neuts-43.9 [MASKED] Monos-10.9 Eos-5.5 Baso-0.3 Im [MASKED] AbsNeut-1.53* AbsLymp-1.34 AbsMono-0.38 AbsEos-0.19 AbsBaso-0.01 [MASKED] 07:25AM BLOOD Plt Ct-63* [MASKED] 07:25AM BLOOD [MASKED] PTT-34.9 [MASKED] [MASKED] 07:25AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-138 K-3.3 Cl-106 HCO3-22 AnGap-13 [MASKED] 07:25AM BLOOD ALT-33 AST-37 AlkPhos-197* TotBili-1.7* [MASKED] 07:25AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.7 Mg-1.[MASKED] with Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who p/w CP and dizziness x1 week. Now found to be hypokalemic and orthostatic--most likely related to anorexia and medication changes. ACS was ruled out on admission. Patient found to be orthostatic and bradycardic, both of which were thought to be contributing to symptoms. Patient received IV fluids and electrolyte repletion with significant improvement. He was seen by nutrition and multivitamin was added. Patient was able to take adequate PO during admission. With regards to his bradycardia, patient was recently started on Metoprolol for new atrial fibrillation. On the medication his heart rate was in 40-50's. We held the medication and he remained in sinus rhythm, with rates in 50-70's. Patient discharged to home with close PCP and cardiology follow up. Transitional Issues ==================== -Patient's Metoprolol held during admission and on discharge, in setting of bradycardia and dizziness. Patient in NSR throughout admission. [MASKED] consider resuming this medicine as outpatient. -Patient has newly diagnosed atrial fibrillation (although currently in sinus as above). CHADSVASC 3. PCP/Cardiologist should discuss risks and benefits of anticoagulation as outpatient. -Patient recently stopped taking Spironolactone. Dr. [MASKED] will determine when/if this medication should be re-started in the outpatient setting. -Patient experienced atypical chest pain prior to admission. ACS ruled out but patient should follow up with cardiology and stress test may be considered. -Patient's QTc noted to be prolonged during admission. This should be monitored in outpatient setting. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg PO BID:PRN Constipation Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Losartan Potassium 100 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN Constipation 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. HELD- Metoprolol Succinate XL 50 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until instructed by your doctor 8. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until instructed by your doctor Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================== Orthostatic Hypotension Hypokalemia secondary to poor PO intake Secondary Diagnosis ==================== Hepatocellular carcinoma 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 pleasure caring for you at [MASKED] [MASKED]. Why was I admitted to the hospital? -You were admitted because of dizziness and chest pain. What was done for me in the hospital? -You had tests that determined you were not having a heart attack. -We gave you IV fluids because you were dehydrated. -You were seen by a nutritionist who recommended you drink Ensure along with your meals and take multivitamin. -We stopped your Metoprolol because your heart rate was low. What should I do at home? -You should NOT take the Metoprolol until directed to do so by your doctor. -[MASKED] should follow up with a cardiologist for your chest pain. They will likely recommend a stress test to determine if you have underlying heart disease. -You should continue to eat and drink regularly at home, and consider supplementing your meals with Ensure. This will prevent you from becoming dehydrated and dizzy. -Please schedule a follow up appointment with your primary care doctor and [MASKED] within the next [MASKED] weeks. -Please schedule an appointment with Cardiology to discuss your chest pain and atrial fibrillation. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I4891", "F17210", "I10", "K219" ]
[ "I951: Orthostatic hypotension", "E876: Hypokalemia", "C220: Liver cell carcinoma", "I4891: Unspecified atrial fibrillation", "Z85038: Personal history of other malignant neoplasm of large intestine", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R079: Chest pain, unspecified", "B1910: Unspecified viral hepatitis B without hepatic coma", "R630: Anorexia", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "Z8619: Personal history of other infectious and parasitic diseases", "I81: Portal vein thrombosis", "R627: Adult failure to thrive", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,052,992
27,263,182
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain, Hypokalemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with hx of Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who presented this evening with CP and 'dizzyness' x1 week. The patient states that he has had CP over the past week intermittently but that it has worsened and become constant over the past few days. No fevers, chronic cough, no palpitations, no vomiting, no diarrhea. Describes anorexia which has been ongoing associated with his cirrhosis. Positional lightheadedness. The patient has undergone a number of medication changes recently. He was recently (___) started on spironolactone for ascites and hypokalemia. On ___ the patient was scheduled for RFA ablation. Prior to the procedure he was noted to be in rapid afib (new for him). It appears the procedure was aborted and the patient was managed with IV metoprolol then sent home on PO metoprolol. His amlodipine was stopped. Felt dizzy after returning home and stopped taking spironolactone. In the ED, the patient was evaluated for ACS and PE. CTPE was without evidence of PE. ECG showed NSR without ischemic change and trop was flat. K+ noted to be low at 2.7. Also found to be orthostatic. Started on K+ repletion. On arrival to the floor, patient states (through son who speaks ___ that he feels a bit better. Chest pain mostly resolved. Still some dizziness, especially when sitting up. Past Medical History: ONCOLOGIC HISTORY: Colon cancer stage IIIB (T3 N1c M0) KRAS w/t MSI stable by ___ - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ Presented with BRBPR - ___ Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. Biopsies revealed adenocarcinoma. CT torso that day showed perforated cholecystitis, a sigmoid colon mass, a 1.5 cm hepatic lesion suspicious for HCC, an adrenal adenoma, and possible mesenteric vasculitis. - ___ Underwent sigmoid colectomy and CCY. Colectomy revealed low grade adenocarcinoma, pT2 pN1c with 15 LNs sampled and negative for disease but with mesenteric deposits of disease (N1c). Margins widely negative, LVI present, PNI present, infiltrating lymphocytes present. KRAS w/t and MSI stable by IHC. - ___ C1D1 FOLFOX6 - ___ C1D15 mFOLFOX 6 (removed ___ bolus and added neulasta for neutropenia and thrombocytopenia) PAST MEDICAL HISTORY 1. Hepatitis B. 2. Hepatitis C. 3. History of hepatitis E infection. 4. Hepatocellular carcinoma (presumed) diagnosed in ___, status post resection in ___ in ___. Presumed hepatocellular carcinoma (new, NOT recurrence) in segment VII, discovered in ___ MRI 5. Cirrhosis complicated by upper GI bleeding from portal hypertensive gastropathy and thrombocytopenia. 6. Hypertension. 7. Hyperlipidemia. 8. GERD. 9. Hearing loss. 10. Sigmoid adenocarcinoma 11. Acute cholecystitis complicated by perforation and subhepatic abscess Social History: ___ Family History: Non contributory Physical Exam: Admission EXAM ============== VS - 98.5 172 / 98 69 16 98 RA General - Lying in bed, NAD HEENT - MMM, OP clear CV - RRR, S1 and S2, no m/r/g Lung - CTAB, no w/r/r Abd - Soft, NT/ND Ext - No c/c/e Skin - No rash Neuro - Alert and oriented. CN II-XII intact. Strength ___ throughout. Smile symmetric. DISCHARGE EXAM ============ VS: 98.0 ___ ___ 18 95RA oriented x 3. HEENT: Sclera anicteric, PERRL. Has dentures on top and bottom. There is some deterioration of the upper denture without signs of infection. No visualiziation of posterior orpharynx. CV: RRR, S1, S2. Distant. Lungs: Diminished bilaterally, no adventitial sounds heard. No tenderness to palpation of the chest. Abdomen: Soft, NT/ND. Extremities: No ___ edema bilaterally. Neurologic: CN II-XII grossly intact. Pertinent Results: ADMISSION LABS ============== ___ 07:15PM BLOOD WBC-5.9# RBC-4.11*# Hgb-13.3*# Hct-41.1# MCV-100* MCH-32.4* MCHC-32.4 RDW-15.8* RDWSD-58.4* Plt ___ ___ 07:15PM BLOOD Neuts-45.2 ___ Monos-13.9* Eos-2.7 Baso-0.3 Im ___ AbsNeut-2.67# AbsLymp-2.22 AbsMono-0.82* AbsEos-0.16 AbsBaso-0.02 ___ 07:15PM BLOOD ___ PTT-38.4* ___ ___ 07:15PM BLOOD Glucose-81 UreaN-13 Creat-1.2 Na-136 K-3.9 Cl-103 HCO3-21* AnGap-16 ___ 07:15PM BLOOD ALT-50* AST-68* AlkPhos-256* TotBili-1.6* ___ 07:15PM BLOOD cTropnT-<0.01 proBNP-15 ___ 07:20AM BLOOD cTropnT-<0.01 ___ 07:15PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.3 Mg-2.0 ___ 10:27PM BLOOD D-Dimer-2736* ___ 11:10PM BLOOD Lactate-2.8* MICRO ====== ___ Urine Culture no growth IMAGING ======= ___ CHEST XRAT IMPRESSION: No acute cardiopulmonary abnormality. ___ CHEST CTA IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Unchanged moderate upper lobe predominant centrilobular and paraseptal emphysema as well as mild, diffuse bronchial wall thickening, consistent with chronic airways disease. 3. Extensive mediastinal lymphadenopathy with at least 1 lymph node larger the prior study. 4. Cirrhotic liver with numerous subcentimeter hypodensities and a large lesion in hepatic segment VII, consistent with known hepatocellular carcinoma. ___ CT HEAD IMPRESSION: 1. Hypodensity of the right temporal lobe and left occipital lobe are noted, without underlying mass effect, potentially representing age-indeterminate infarcts given the patient's clinical history and without prior imaging for comparison. Further evaluation with MRI with and without contrast (given the patient's history of ___ and colon cancer) is recommended, if there are no contraindications. DISCHARGE LABS ============= ___ 07:23AM BLOOD Lactate-2.3* ___ 07:45AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 ___ 07:45AM BLOOD ALT-44* AST-58* LD(LDH)-196 AlkPhos-202* TotBili-1.5 ___ 07:45AM BLOOD Glucose-101* UreaN-13 Creat-1.1 Na-139 K-3.9 Cl-107 HCO3-23 AnGap-13 ___ 07:45AM BLOOD Plt Ct-62* ___ 07:45AM BLOOD WBC-2.9* RBC-3.50* Hgb-11.4* Hct-34.1* MCV-97 MCH-32.6* MCHC-33.4 RDW-15.5 RDWSD-55.9* Plt Ct-62* Brief Hospital Course: ASSESSMENT AND PLAN: Mr. ___ is a ___ year old male, with history of Hepatitis B, Hepatitis C, cirrhosis c/b with HCC, and colon cancer (stage IIIb) currently in remission, atrial fibrillation, now presenting with intermittent chest pains, fatigue, and poor PO intake. # Chest Pain: Unclear etiology, with intermittent chest discomfort. Patient had similar symptoms previously, does have some findings concerning for chronic airway disease and some increased mediastinal lymphadenopathy, unclear if previously investigated. Patient did not have symptoms on the floor. Negative CTA for PE or ACS (ruled out x 2 trops). # Fatigue # Hemoconcentration # Malnutrition: Suspect behind in volume status, and increased fatigue ___ to dehydration. Unclear if specific reason given no significant abdominal pain or other abdominal symptoms, however significantly hemoconcentrated, with urine spec ___ > 1050. This improved with volume resuscitation. # Paroxysmal atrial fibrillation: Found to have bradycardia previously with increased QTc, metoprolol held, no anticoagulation. CHADS2Vasc=3. EKG on arrival was sinus. Rate control agents were not given due to bradycardia. He was discharged with outpatient cardiology follow up. # Dizziness: Unclear etiology, likely ___ to overall dehydration albeit negative orthostatics. Not classic for other vertigo type sensations. No dedicated head imaging in system. CT head showed no underlying mass effect however radiology recommended MRI, but unable to obtain given clip in body recent. # Hepatitis B, Hepatitis C Cirrhosis: MELD-Na score 12. Now scheduled for RFA ablation in ___. Not a candidate for transplantation. Spironolactone was held due to hypovolemia. He was continued on his tenofovir. # Colon Cancer: Stage IIIB, in remission. Curative intent, adjuvant therapy, requiring annual imaging. # Thrombocytopenia: Related to underlying cirrhosis, at this point concentrated > 100 with baseline in 50-60s. # ___: patient with elevated Cr to 1.2, baseline is 0.8, suspect dehydration and hypovolemia. After resusitation Cr. trended down. #Hypertension- patient takes Losartan as outpatient but it was held in setting ___ and normotension. It was restarted upon discharge. Transitional issues ================== # Chest pain- resolved. unclear etiology (negative CTA/troponins/ecg)- please monitor for future episodes of chest pain # Paroxysmal atrial fibrillation- Sinus rhythm. evaluate rhythm and consider need for rate control/anticoagulation. CHADS2Vasc=3 # Dizziness- unclear etiology -MRI could not be done due to clip placement in last month. can due after ___. # Colon Cancer- remission, adjuvant therapy with currative intent. Follow up outpatient Onc recommendations. #malnutrition- please encourage him to eat and consider addition of medications to increase appetite if continues to loose weight. #HTN- BP within normal limits while admitted. Please assess need/safety of restarting lisinopril. #Cirrhosis - Held spironolactone due to dehydration. Held upon discharge. Please reassess need/safety of restarting. #pAF: Patient's metoprolol held given bradycardia to the ___ #Hypertension: Patient has history of hypertension, however blood pressures normal despite anti-HTN being held. Please re-evaluate and restart as needed. # Services: patient was set up with elder services upon discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID:PRN Constipation 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID:PRN Constipation 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary ======== 1. Acute Kidney Injury 2. Atypical Chest Pain 3. Dehydration SECONDARY DIAGNOSIS =========== Paroxysmal atrial fibrillation Hepatitis B, Hepatitis C Cirrhosis Colon Cancer 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 during your stay at ___. You were admitted to the hospital due to dizziness, chest pain, and kidney damage due to dehydration. While you were in the Hospital you received fluids which improved your kidney function. To assess your dizziness a CT scan which was negative for any acute issues. Your chest pain resolved while in the hospital and ekg and blood work showed the pain was not from your heart. You will have follow-up with your interventional radiology team tomorrow on ___, for RFA ablation. Please follow-up with your liver specialists and your primary care physician. Please continue to take all of your home medications as prescribed. Best, Your ___ team Followup Instructions: ___
[ "N179", "B1910", "E46", "E860", "I480", "D6959", "I10", "E785", "R0789", "B1920", "Z85038", "Z8505", "K219", "F17210", "Z6825", "E861" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain, Hypokalemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with hx of Hep B/Hep C cirrhosis, recurrent HCC c/b non-occlusive PVT, Colon Ca (IIIB, in remission), and atrial fibrillation who presented this evening with CP and 'dizzyness' x1 week. The patient states that he has had CP over the past week intermittently but that it has worsened and become constant over the past few days. No fevers, chronic cough, no palpitations, no vomiting, no diarrhea. Describes anorexia which has been ongoing associated with his cirrhosis. Positional lightheadedness. The patient has undergone a number of medication changes recently. He was recently ([MASKED]) started on spironolactone for ascites and hypokalemia. On [MASKED] the patient was scheduled for RFA ablation. Prior to the procedure he was noted to be in rapid afib (new for him). It appears the procedure was aborted and the patient was managed with IV metoprolol then sent home on PO metoprolol. His amlodipine was stopped. Felt dizzy after returning home and stopped taking spironolactone. In the ED, the patient was evaluated for ACS and PE. CTPE was without evidence of PE. ECG showed NSR without ischemic change and trop was flat. K+ noted to be low at 2.7. Also found to be orthostatic. Started on K+ repletion. On arrival to the floor, patient states (through son who speaks [MASKED] that he feels a bit better. Chest pain mostly resolved. Still some dizziness, especially when sitting up. Past Medical History: ONCOLOGIC HISTORY: Colon cancer stage IIIB (T3 N1c M0) KRAS w/t MSI stable by [MASKED] - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] Presented with BRBPR - [MASKED] Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. Biopsies revealed adenocarcinoma. CT torso that day showed perforated cholecystitis, a sigmoid colon mass, a 1.5 cm hepatic lesion suspicious for HCC, an adrenal adenoma, and possible mesenteric vasculitis. - [MASKED] Underwent sigmoid colectomy and CCY. Colectomy revealed low grade adenocarcinoma, pT2 pN1c with 15 LNs sampled and negative for disease but with mesenteric deposits of disease (N1c). Margins widely negative, LVI present, PNI present, infiltrating lymphocytes present. KRAS w/t and MSI stable by IHC. - [MASKED] C1D1 FOLFOX6 - [MASKED] C1D15 mFOLFOX 6 (removed [MASKED] bolus and added neulasta for neutropenia and thrombocytopenia) PAST MEDICAL HISTORY 1. Hepatitis B. 2. Hepatitis C. 3. History of hepatitis E infection. 4. Hepatocellular carcinoma (presumed) diagnosed in [MASKED], status post resection in [MASKED] in [MASKED]. Presumed hepatocellular carcinoma (new, NOT recurrence) in segment VII, discovered in [MASKED] MRI 5. Cirrhosis complicated by upper GI bleeding from portal hypertensive gastropathy and thrombocytopenia. 6. Hypertension. 7. Hyperlipidemia. 8. GERD. 9. Hearing loss. 10. Sigmoid adenocarcinoma 11. Acute cholecystitis complicated by perforation and subhepatic abscess Social History: [MASKED] Family History: Non contributory Physical Exam: Admission EXAM ============== VS - 98.5 172 / 98 69 16 98 RA General - Lying in bed, NAD HEENT - MMM, OP clear CV - RRR, S1 and S2, no m/r/g Lung - CTAB, no w/r/r Abd - Soft, NT/ND Ext - No c/c/e Skin - No rash Neuro - Alert and oriented. CN II-XII intact. Strength [MASKED] throughout. Smile symmetric. DISCHARGE EXAM ============ VS: 98.0 [MASKED] [MASKED] 18 95RA oriented x 3. HEENT: Sclera anicteric, PERRL. Has dentures on top and bottom. There is some deterioration of the upper denture without signs of infection. No visualiziation of posterior orpharynx. CV: RRR, S1, S2. Distant. Lungs: Diminished bilaterally, no adventitial sounds heard. No tenderness to palpation of the chest. Abdomen: Soft, NT/ND. Extremities: No [MASKED] edema bilaterally. Neurologic: CN II-XII grossly intact. Pertinent Results: ADMISSION LABS ============== [MASKED] 07:15PM BLOOD WBC-5.9# RBC-4.11*# Hgb-13.3*# Hct-41.1# MCV-100* MCH-32.4* MCHC-32.4 RDW-15.8* RDWSD-58.4* Plt [MASKED] [MASKED] 07:15PM BLOOD Neuts-45.2 [MASKED] Monos-13.9* Eos-2.7 Baso-0.3 Im [MASKED] AbsNeut-2.67# AbsLymp-2.22 AbsMono-0.82* AbsEos-0.16 AbsBaso-0.02 [MASKED] 07:15PM BLOOD [MASKED] PTT-38.4* [MASKED] [MASKED] 07:15PM BLOOD Glucose-81 UreaN-13 Creat-1.2 Na-136 K-3.9 Cl-103 HCO3-21* AnGap-16 [MASKED] 07:15PM BLOOD ALT-50* AST-68* AlkPhos-256* TotBili-1.6* [MASKED] 07:15PM BLOOD cTropnT-<0.01 proBNP-15 [MASKED] 07:20AM BLOOD cTropnT-<0.01 [MASKED] 07:15PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.3 Mg-2.0 [MASKED] 10:27PM BLOOD D-Dimer-2736* [MASKED] 11:10PM BLOOD Lactate-2.8* MICRO ====== [MASKED] Urine Culture no growth IMAGING ======= [MASKED] CHEST XRAT IMPRESSION: No acute cardiopulmonary abnormality. [MASKED] CHEST CTA IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Unchanged moderate upper lobe predominant centrilobular and paraseptal emphysema as well as mild, diffuse bronchial wall thickening, consistent with chronic airways disease. 3. Extensive mediastinal lymphadenopathy with at least 1 lymph node larger the prior study. 4. Cirrhotic liver with numerous subcentimeter hypodensities and a large lesion in hepatic segment VII, consistent with known hepatocellular carcinoma. [MASKED] CT HEAD IMPRESSION: 1. Hypodensity of the right temporal lobe and left occipital lobe are noted, without underlying mass effect, potentially representing age-indeterminate infarcts given the patient's clinical history and without prior imaging for comparison. Further evaluation with MRI with and without contrast (given the patient's history of [MASKED] and colon cancer) is recommended, if there are no contraindications. DISCHARGE LABS ============= [MASKED] 07:23AM BLOOD Lactate-2.3* [MASKED] 07:45AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 [MASKED] 07:45AM BLOOD ALT-44* AST-58* LD(LDH)-196 AlkPhos-202* TotBili-1.5 [MASKED] 07:45AM BLOOD Glucose-101* UreaN-13 Creat-1.1 Na-139 K-3.9 Cl-107 HCO3-23 AnGap-13 [MASKED] 07:45AM BLOOD Plt Ct-62* [MASKED] 07:45AM BLOOD WBC-2.9* RBC-3.50* Hgb-11.4* Hct-34.1* MCV-97 MCH-32.6* MCHC-33.4 RDW-15.5 RDWSD-55.9* Plt Ct-62* Brief Hospital Course: ASSESSMENT AND PLAN: Mr. [MASKED] is a [MASKED] year old male, with history of Hepatitis B, Hepatitis C, cirrhosis c/b with HCC, and colon cancer (stage IIIb) currently in remission, atrial fibrillation, now presenting with intermittent chest pains, fatigue, and poor PO intake. # Chest Pain: Unclear etiology, with intermittent chest discomfort. Patient had similar symptoms previously, does have some findings concerning for chronic airway disease and some increased mediastinal lymphadenopathy, unclear if previously investigated. Patient did not have symptoms on the floor. Negative CTA for PE or ACS (ruled out x 2 trops). # Fatigue # Hemoconcentration # Malnutrition: Suspect behind in volume status, and increased fatigue [MASKED] to dehydration. Unclear if specific reason given no significant abdominal pain or other abdominal symptoms, however significantly hemoconcentrated, with urine spec [MASKED] > 1050. This improved with volume resuscitation. # Paroxysmal atrial fibrillation: Found to have bradycardia previously with increased QTc, metoprolol held, no anticoagulation. CHADS2Vasc=3. EKG on arrival was sinus. Rate control agents were not given due to bradycardia. He was discharged with outpatient cardiology follow up. # Dizziness: Unclear etiology, likely [MASKED] to overall dehydration albeit negative orthostatics. Not classic for other vertigo type sensations. No dedicated head imaging in system. CT head showed no underlying mass effect however radiology recommended MRI, but unable to obtain given clip in body recent. # Hepatitis B, Hepatitis C Cirrhosis: MELD-Na score 12. Now scheduled for RFA ablation in [MASKED]. Not a candidate for transplantation. Spironolactone was held due to hypovolemia. He was continued on his tenofovir. # Colon Cancer: Stage IIIB, in remission. Curative intent, adjuvant therapy, requiring annual imaging. # Thrombocytopenia: Related to underlying cirrhosis, at this point concentrated > 100 with baseline in 50-60s. # [MASKED]: patient with elevated Cr to 1.2, baseline is 0.8, suspect dehydration and hypovolemia. After resusitation Cr. trended down. #Hypertension- patient takes Losartan as outpatient but it was held in setting [MASKED] and normotension. It was restarted upon discharge. Transitional issues ================== # Chest pain- resolved. unclear etiology (negative CTA/troponins/ecg)- please monitor for future episodes of chest pain # Paroxysmal atrial fibrillation- Sinus rhythm. evaluate rhythm and consider need for rate control/anticoagulation. CHADS2Vasc=3 # Dizziness- unclear etiology -MRI could not be done due to clip placement in last month. can due after [MASKED]. # Colon Cancer- remission, adjuvant therapy with currative intent. Follow up outpatient Onc recommendations. #malnutrition- please encourage him to eat and consider addition of medications to increase appetite if continues to loose weight. #HTN- BP within normal limits while admitted. Please assess need/safety of restarting lisinopril. #Cirrhosis - Held spironolactone due to dehydration. Held upon discharge. Please reassess need/safety of restarting. #pAF: Patient's metoprolol held given bradycardia to the [MASKED] #Hypertension: Patient has history of hypertension, however blood pressures normal despite anti-HTN being held. Please re-evaluate and restart as needed. # Services: patient was set up with elder services upon discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID:PRN Constipation 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID:PRN Constipation 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary ======== 1. Acute Kidney Injury 2. Atypical Chest Pain 3. Dehydration SECONDARY DIAGNOSIS =========== Paroxysmal atrial fibrillation Hepatitis B, Hepatitis C Cirrhosis Colon Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you during your stay at [MASKED]. You were admitted to the hospital due to dizziness, chest pain, and kidney damage due to dehydration. While you were in the Hospital you received fluids which improved your kidney function. To assess your dizziness a CT scan which was negative for any acute issues. Your chest pain resolved while in the hospital and ekg and blood work showed the pain was not from your heart. You will have follow-up with your interventional radiology team tomorrow on [MASKED], for RFA ablation. Please follow-up with your liver specialists and your primary care physician. Please continue to take all of your home medications as prescribed. Best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "I480", "I10", "E785", "K219", "F17210" ]
[ "N179: Acute kidney failure, unspecified", "B1910: Unspecified viral hepatitis B without hepatic coma", "E46: Unspecified protein-calorie malnutrition", "E860: Dehydration", "I480: Paroxysmal atrial fibrillation", "D6959: Other secondary thrombocytopenia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "R0789: Other chest pain", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z8505: Personal history of malignant neoplasm of liver", "K219: Gastro-esophageal reflux disease without esophagitis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "E861: Hypovolemia" ]
10,052,992
27,584,154
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: s/p TACE Major Surgical or Invasive Procedure: Transarterial chemoembolization ___ FINDINGS: 1. Conventional celiac and hepatic arterial anatomy. 2. Pre-embolization arteriogram and cone beam CT showing tumor blush in segment VI. 4. Post-embolization showing staining of tumor in segment VI with inflow arterial stasis. IMPRESSION: Successful left greater artery approach trans-arterial chemoembolization of HCC located in segment VI. History of Present Illness: This is a ___ male with colon cancer (T3 N1 M0) s/p resection on ___ and FOLFOX, HCV/HBV cirrhosis (compensated) with hepatocellular carcinoma, status post multiple RFA, admitted s/p TACE for 2.2-cm segment VI HCC recurrence. He presented today for planned transcatheter arterial chemoembolization with left radial access. He received 1L NS, fentanyl and oxycodone. He tolerated the procedure well. In the PACU, he was note to be wheezing and was given a neb from which he improved. On arrival to the floor, he reports feeling well. History is obtained with interpreter and son's assistance. The patient is not able to confirm the date or specify which hospital he is in, which the son reports is his usual. He reports no pain, no trouble with breathing, no chest discomfort. ROS: Per hpi, otherwise rest of 10pt review negative. Past Medical History: PAST ONCOLOGIC HISTORY: Hepatocellular carcinoma in the setting of HCV, HBV, and possible alcoholic cirrhosis - ___ Resection of a primary HCC by report - ___ Presented with worsening abdominal pain. - ___ EGD revealed grade I varices and a gastric ulcer - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since ___, however now meets OPTN 5a criteria for HCC. New 1.2 x 1 cm arterially hyperenhancing segment VIII lesion does not meet strict OPTN-5 criteria but is suspicious for HCC. - ___ RFA of the larger segment VIII lesion - ___ MR liver showed full treatment of the segment VIII lesion, stable segment VII lesion - ___ CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - ___ PET ___ - ___ CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - ___ RFA to his recurrent HCC - ___ CT abdomen showed a 2.2 cm segment VI HCC by OPTN - ___ MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - ___ Presented with BRBPR - ___ Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. - ___ Underwent sigmoid colectomy and CCY. - ___ C1D1 FOLFOX6 - ___ C2D1 modified FOLFOX (no bolus ___, LV 200 mg/m2, oxaliplatin 65 mg/m2) + Neulasta delayed and reduced for cytopenias and liver injury - ___ dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection - ___ Holding further chemo for past toxicity - ___ CT torso ___ - ___ MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since ___, however now meets OPTN 5a criteria for HCC. - ___ Colonoscopy with poor prep, at least one adenoma identified and removed - ___ CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - ___ PET ___ - ___ CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - ___ Colonoscopy showed 2 polyps, GI recommended repeat in ___ years - ___ CT abdomen showed a 2.2 cm segment VI HCC by OPTN criteria, no metastatic disease Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: T 100.6 BP 117/66 HR 93 RR 18 O2 96%RA GEN: Elderly man in no acute distress, breathing slightly labored HEENT: Moist membranes, anicteric NECK: No masses HEART: RRR, no murmurs LUNGS: Insp/expiratory wheeze, slightly labored breathing but comfortable ABD: Soft, nontender, nondistended, no fluid wave GU: No foley EXT: Warm, no edema NEURO: Prominent asterixis, alert, oriented to self and hospital only DISCHARGE PE VS: T 98.8 BP 113 / 66 HR 87 RR 18 O2 sat 94 ra Gen: NAD, resting, ___ interpretation with son Eyes: ___, no scleral icterus HENT: NCAT, trachea midline CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ ___ BLE Lungs: CTA B, no w/r/r/c GI: +BS, soft, NTTP, ND, no grimace to palpation with RUQ GU: No foley MSK: ___ strength bilaterally, intact ROM Neuro: Moving all extremities, no focal deficits, A+O to place, ___, hospital but not year (never knows year), knows ___ time but not exact date which is baseline, knows birthday and oriented to situation/person. Skin: No rash or ecchymosis Psych: Congruent affect, good judgment Pertinent Results: ADMISSION LABS: ___ 09:45PM BLOOD WBC-7.5# RBC-3.24* Hgb-10.1* Hct-30.8* MCV-95 MCH-31.2 MCHC-32.8 RDW-15.6* RDWSD-54.3* Plt Ct-55* ___ 09:45PM BLOOD ___ ___ 09:45PM BLOOD Glucose-192* UreaN-9 Creat-1.0 Na-142 K-2.5* Cl-107 HCO3-21* AnGap-17 ___ 10:40AM BLOOD ALT-36 AST-61* AlkPhos-218* TotBili-2.4* ___ 10:40AM BLOOD CEA-2.9 AFP-1437.0* DISCHARGE LABS: ___ 08:50AM BLOOD WBC-5.1 RBC-3.06* Hgb-9.6* Hct-29.6* MCV-97 MCH-31.4 MCHC-32.4 RDW-15.7* RDWSD-55.7* Plt Ct-55* ___ 07:30AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-141 K-3.5 Cl-111* HCO3-19* AnGap-15 ___ 07:30AM BLOOD ALT-64* AST-121* AlkPhos-183* TotBili-1.9* CT a/p ___ Pending read will f/u with hepatologist for results Brief Hospital Course: ASSESSMENT AND PLAN: This is a ___ male with colon cancer (T3 N1 M0) s/p resection on ___ and FOLFOX, HCV/HBV cirrhosis (compensated) with hepatocellular carcinoma, status post multiple RFA, admitted s/p TACE for 2.2-cm segment VI HCC recurrence. # s/p TACE # HCC, recurrent Tolerated TACE well, minimal pain at present, abd exam benign. - noncontrast CT done pending read - will f/u with hepatologist on results - Pain and nausea is controlled at time of discharge # Acute encephalopathy - post procedure but resolved with sleep overnight. Pt is at baseline orientation per family (knows place, situation, DOB, people, location, but not date/year/month which is normal) # Wheeze # Active smoker CXR without evidence of aspiration or fluid overload from IVF during procedure, breathing comfortably. - f/u with PCP ___ ?if COPD is a possibility and PFTs # Hypokalemia K 2.5. repleted with 120 mEq and 40 mEq IV with discharge K 3.5. # HCV/HBC cirrhosis Has asterixis, unclear if this is baseline or triggered by anesthesia, not on hepatic encephalopathy meds. Improved in am likely post anesthesia effect. - cont tenofovir 300mg daily # Essential HTN- controlled - restart losartan 100mg daily CODE- presumed full Discharge to home without services Pt met inpatient criteria with K 2.5 and encephalopathy post procedure. He improved faster than expected. >30 minutes was spent on this discharge with coordinating follow-up, discussing with son, interpretation, and communication with ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Losartan Potassium 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN Constipation 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. Post TACE/HCC 2. Acute Encephalopathy resolved 3. Hypokalemia - resolved 4. Wheezing - no O2 requirements 5. Abdominal Pain - resolved 6. HBV/HCV Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for a transarterial chemoembolization of your liver cancer. The procedure went well. You were slightly confused after the procedure but that has cleared this morning. You could expect to have low grade fevers, abdominal pain in your right upper abdomen, and nausea/vomiting post this procedure. Please check in with your hepatologist if these occur for instructions. You had a CT scan of your belly to see the end results of your embolization. You will have the results when you follow-up with your hepatologist. Followup Instructions: ___
[ "Z5111", "G9340", "C220", "B1910", "B1920", "E876", "F17210", "I10", "Z85038", "K7460" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p TACE Major Surgical or Invasive Procedure: Transarterial chemoembolization [MASKED] FINDINGS: 1. Conventional celiac and hepatic arterial anatomy. 2. Pre-embolization arteriogram and cone beam CT showing tumor blush in segment VI. 4. Post-embolization showing staining of tumor in segment VI with inflow arterial stasis. IMPRESSION: Successful left greater artery approach trans-arterial chemoembolization of HCC located in segment VI. History of Present Illness: This is a [MASKED] male with colon cancer (T3 N1 M0) s/p resection on [MASKED] and FOLFOX, HCV/HBV cirrhosis (compensated) with hepatocellular carcinoma, status post multiple RFA, admitted s/p TACE for 2.2-cm segment VI HCC recurrence. He presented today for planned transcatheter arterial chemoembolization with left radial access. He received 1L NS, fentanyl and oxycodone. He tolerated the procedure well. In the PACU, he was note to be wheezing and was given a neb from which he improved. On arrival to the floor, he reports feeling well. History is obtained with interpreter and son's assistance. The patient is not able to confirm the date or specify which hospital he is in, which the son reports is his usual. He reports no pain, no trouble with breathing, no chest discomfort. ROS: Per hpi, otherwise rest of 10pt review negative. Past Medical History: PAST ONCOLOGIC HISTORY: Hepatocellular carcinoma in the setting of HCV, HBV, and possible alcoholic cirrhosis - [MASKED] Resection of a primary HCC by report - [MASKED] Presented with worsening abdominal pain. - [MASKED] EGD revealed grade I varices and a gastric ulcer - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since [MASKED], however now meets OPTN 5a criteria for HCC. New 1.2 x 1 cm arterially hyperenhancing segment VIII lesion does not meet strict OPTN-5 criteria but is suspicious for HCC. - [MASKED] RFA of the larger segment VIII lesion - [MASKED] MR liver showed full treatment of the segment VIII lesion, stable segment VII lesion - [MASKED] CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - [MASKED] PET [MASKED] - [MASKED] CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - [MASKED] RFA to his recurrent HCC - [MASKED] CT abdomen showed a 2.2 cm segment VI HCC by OPTN - [MASKED] MR liver revealed a cirrhotic liver with 1.8 cm lesion in segment VII suspicious for HCC but not meeting strict OPTN 5a criteria as well as possible cholecystitis - [MASKED] Presented with BRBPR - [MASKED] Colonoscopy revealed a 5 cm bleeding mass at 25 cm in the sigmoid colon. - [MASKED] Underwent sigmoid colectomy and CCY. - [MASKED] C1D1 FOLFOX6 - [MASKED] C2D1 modified FOLFOX (no bolus [MASKED], LV 200 mg/m2, oxaliplatin 65 mg/m2) + Neulasta delayed and reduced for cytopenias and liver injury - [MASKED] dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection - [MASKED] Holding further chemo for past toxicity - [MASKED] CT torso [MASKED] - [MASKED] MR liver showed a 1.7 x 1.3 cm segment VII hepatic lesion is unchanged in size since [MASKED], however now meets OPTN 5a criteria for HCC. - [MASKED] Colonoscopy with poor prep, at least one adenoma identified and removed - [MASKED] CT torso showed the arterial hyperenhancing lesion in segment VIII does not demonstrate washout and does not meet criteria for an OPTN 5 lesion, however has grown in size compared with the prior study measuring 2.6 cm, previously 1.7 cm. Interval increase size of a low-density lymph node with internal calcification posterior to the IVC and a small aortocaval lymph node. PET scan is recommended. - [MASKED] PET [MASKED] - [MASKED] CT torso showed a 3.0 cm arterially enhancing lesion within segment VII shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma (OPTN class 5B). New portal vein thrombosis and evidence of portal hypertension. No metastatic disease. - [MASKED] Colonoscopy showed 2 polyps, GI recommended repeat in [MASKED] years - [MASKED] CT abdomen showed a 2.2 cm segment VI HCC by OPTN criteria, no metastatic disease Social History: [MASKED] Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: T 100.6 BP 117/66 HR 93 RR 18 O2 96%RA GEN: Elderly man in no acute distress, breathing slightly labored HEENT: Moist membranes, anicteric NECK: No masses HEART: RRR, no murmurs LUNGS: Insp/expiratory wheeze, slightly labored breathing but comfortable ABD: Soft, nontender, nondistended, no fluid wave GU: No foley EXT: Warm, no edema NEURO: Prominent asterixis, alert, oriented to self and hospital only DISCHARGE PE VS: T 98.8 BP 113 / 66 HR 87 RR 18 O2 sat 94 ra Gen: NAD, resting, [MASKED] interpretation with son Eyes: [MASKED], no scleral icterus HENT: NCAT, trachea midline CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ [MASKED] BLE Lungs: CTA B, no w/r/r/c GI: +BS, soft, NTTP, ND, no grimace to palpation with RUQ GU: No foley MSK: [MASKED] strength bilaterally, intact ROM Neuro: Moving all extremities, no focal deficits, A+O to place, [MASKED], hospital but not year (never knows year), knows [MASKED] time but not exact date which is baseline, knows birthday and oriented to situation/person. Skin: No rash or ecchymosis Psych: Congruent affect, good judgment Pertinent Results: ADMISSION LABS: [MASKED] 09:45PM BLOOD WBC-7.5# RBC-3.24* Hgb-10.1* Hct-30.8* MCV-95 MCH-31.2 MCHC-32.8 RDW-15.6* RDWSD-54.3* Plt Ct-55* [MASKED] 09:45PM BLOOD [MASKED] [MASKED] 09:45PM BLOOD Glucose-192* UreaN-9 Creat-1.0 Na-142 K-2.5* Cl-107 HCO3-21* AnGap-17 [MASKED] 10:40AM BLOOD ALT-36 AST-61* AlkPhos-218* TotBili-2.4* [MASKED] 10:40AM BLOOD CEA-2.9 AFP-1437.0* DISCHARGE LABS: [MASKED] 08:50AM BLOOD WBC-5.1 RBC-3.06* Hgb-9.6* Hct-29.6* MCV-97 MCH-31.4 MCHC-32.4 RDW-15.7* RDWSD-55.7* Plt Ct-55* [MASKED] 07:30AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-141 K-3.5 Cl-111* HCO3-19* AnGap-15 [MASKED] 07:30AM BLOOD ALT-64* AST-121* AlkPhos-183* TotBili-1.9* CT a/p [MASKED] Pending read will f/u with hepatologist for results Brief Hospital Course: ASSESSMENT AND PLAN: This is a [MASKED] male with colon cancer (T3 N1 M0) s/p resection on [MASKED] and FOLFOX, HCV/HBV cirrhosis (compensated) with hepatocellular carcinoma, status post multiple RFA, admitted s/p TACE for 2.2-cm segment VI HCC recurrence. # s/p TACE # HCC, recurrent Tolerated TACE well, minimal pain at present, abd exam benign. - noncontrast CT done pending read - will f/u with hepatologist on results - Pain and nausea is controlled at time of discharge # Acute encephalopathy - post procedure but resolved with sleep overnight. Pt is at baseline orientation per family (knows place, situation, DOB, people, location, but not date/year/month which is normal) # Wheeze # Active smoker CXR without evidence of aspiration or fluid overload from IVF during procedure, breathing comfortably. - f/u with PCP [MASKED] ?if COPD is a possibility and PFTs # Hypokalemia K 2.5. repleted with 120 mEq and 40 mEq IV with discharge K 3.5. # HCV/HBC cirrhosis Has asterixis, unclear if this is baseline or triggered by anesthesia, not on hepatic encephalopathy meds. Improved in am likely post anesthesia effect. - cont tenofovir 300mg daily # Essential HTN- controlled - restart losartan 100mg daily CODE- presumed full Discharge to home without services Pt met inpatient criteria with K 2.5 and encephalopathy post procedure. He improved faster than expected. >30 minutes was spent on this discharge with coordinating follow-up, discussing with son, interpretation, and communication with [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Losartan Potassium 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN Constipation 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. Post TACE/HCC 2. Acute Encephalopathy resolved 3. Hypokalemia - resolved 4. Wheezing - no O2 requirements 5. Abdominal Pain - resolved 6. HBV/HCV Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted for a transarterial chemoembolization of your liver cancer. The procedure went well. You were slightly confused after the procedure but that has cleared this morning. You could expect to have low grade fevers, abdominal pain in your right upper abdomen, and nausea/vomiting post this procedure. Please check in with your hepatologist if these occur for instructions. You had a CT scan of your belly to see the end results of your embolization. You will have the results when you follow-up with your hepatologist. Followup Instructions: [MASKED]
[]
[ "F17210", "I10" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "G9340: Encephalopathy, unspecified", "C220: Liver cell carcinoma", "B1910: Unspecified viral hepatitis B without hepatic coma", "B1920: Unspecified viral hepatitis C without hepatic coma", "E876: Hypokalemia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "Z85038: Personal history of other malignant neoplasm of large intestine", "K7460: Unspecified cirrhosis of liver" ]
10,053,000
28,772,209
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / Tetracycline Attending: ___. Chief Complaint: acute diverticulitis Major Surgical or Invasive Procedure: none History of Present Illness: ___ man with history of ANCA positive vasculitis on chronic prednisone,who presents to the ED after 3 days of abdominal pain. Patient reports that he has been having periumbilical bandlike pain since 3 days ago that worsened 1 day ago after a large meal. He continues to pass gas his last bowel movement was yesterday and that was normal, and he does not endorse nausea vomiting. Patient reports that his last episode of diverticulitis was in ___ and his last colonoscopy was done to ___ years ago and was negative. He is admitted to the ED for evaluation of his acute diverticulitis that was found on CT that shows 1.6 cm phlegmonous change in the ascending colon. No drainable collection. He is otherwise feeling well. Past Medical History: HYPERTENSION Hypercholesterolemia ANCA-associated vasculitis Wegener's granulomatosis (granulomatosis with polyangiitis) I do not think he will likely need the medicine BPH (benign prostatic hyperplasia) The patient is having really like seeing the patient because he was cutting the Mosaic Klinefelter syndrome Social History: ___ Family History: No family history of IBD, grandfather with colon cancer at age of ___ Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, mildly tender to palpation on the right lower quadrant, no rebound or guarding, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 02:40PM GLUCOSE-107* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-28 ANION GAP-17 ___ 02:40PM estGFR-Using this ___ 02:40PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-81 TOT BILI-0.9 ___ 02:40PM LIPASE-42 ___ 02:40PM ALBUMIN-4.4 ___ 02:40PM NEUTS-84.2* LYMPHS-5.8* MONOS-8.4 EOS-0.9* BASOS-0.2 IM ___ AbsNeut-14.52* AbsLymp-1.01* AbsMono-1.45* AbsEos-0.16 AbsBaso-0.04 ___ 02:40PM PLT COUNT-238 ___ 02:40PM PLT COUNT-238 ___ 02:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Brief Hospital Course: ___ w h/o ANCA+ vasculitis on chronic steroid p/w acute diverticulitis. The patient was placed on IV abx and pain meds. The patients pain improved on HD2. ON HD3, Mr. ___ was transitioned to PO Abx and pain peds. He was given a regular diet. Mr. ___ was discharged from the hospital on HD3 in stable condition. He was tolearing a regular diet, voiding, but still mildly tender on abdominal exam. He was asked to follow up in ___ clinic and placed on a total of 10 days of cipro/flagyl. Medications on Admission: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 3. amLODIPine 2.5 mg PO DAILY 4. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 5. amLODIPine 2.5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
[ "K5720", "I10", "I776", "E7800" ]
Allergies: Penicillins / Tetracycline Chief Complaint: acute diverticulitis Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] man with history of ANCA positive vasculitis on chronic prednisone,who presents to the ED after 3 days of abdominal pain. Patient reports that he has been having periumbilical bandlike pain since 3 days ago that worsened 1 day ago after a large meal. He continues to pass gas his last bowel movement was yesterday and that was normal, and he does not endorse nausea vomiting. Patient reports that his last episode of diverticulitis was in [MASKED] and his last colonoscopy was done to [MASKED] years ago and was negative. He is admitted to the ED for evaluation of his acute diverticulitis that was found on CT that shows 1.6 cm phlegmonous change in the ascending colon. No drainable collection. He is otherwise feeling well. Past Medical History: HYPERTENSION Hypercholesterolemia ANCA-associated vasculitis Wegener's granulomatosis (granulomatosis with polyangiitis) I do not think he will likely need the medicine BPH (benign prostatic hyperplasia) The patient is having really like seeing the patient because he was cutting the Mosaic Klinefelter syndrome Social History: [MASKED] Family History: No family history of IBD, grandfather with colon cancer at age of [MASKED] Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, mildly tender to palpation on the right lower quadrant, no rebound or guarding, no palpable masses DRE: normal tone, no gross or occult blood Ext: No [MASKED] edema, [MASKED] warm and well perfused Pertinent Results: [MASKED] 02:40PM GLUCOSE-107* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-28 ANION GAP-17 [MASKED] 02:40PM estGFR-Using this [MASKED] 02:40PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-81 TOT BILI-0.9 [MASKED] 02:40PM LIPASE-42 [MASKED] 02:40PM ALBUMIN-4.4 [MASKED] 02:40PM NEUTS-84.2* LYMPHS-5.8* MONOS-8.4 EOS-0.9* BASOS-0.2 IM [MASKED] AbsNeut-14.52* AbsLymp-1.01* AbsMono-1.45* AbsEos-0.16 AbsBaso-0.04 [MASKED] 02:40PM PLT COUNT-238 [MASKED] 02:40PM PLT COUNT-238 [MASKED] 02:30PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Brief Hospital Course: [MASKED] w h/o ANCA+ vasculitis on chronic steroid p/w acute diverticulitis. The patient was placed on IV abx and pain meds. The patients pain improved on HD2. ON HD3, Mr. [MASKED] was transitioned to PO Abx and pain peds. He was given a regular diet. Mr. [MASKED] was discharged from the hospital on HD3 in stable condition. He was tolearing a regular diet, voiding, but still mildly tender on abdominal exam. He was asked to follow up in [MASKED] clinic and placed on a total of 10 days of cipro/flagyl. Medications on Admission: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 3. amLODIPine 2.5 mg PO DAILY 4. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 5. amLODIPine 2.5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: [MASKED]
[]
[ "I10" ]
[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "I10: Essential (primary) hypertension", "I776: Arteritis, unspecified", "E7800: Pure hypercholesterolemia, unspecified" ]
10,053,139
26,871,759
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: penicillin Attending: ___ Chief Complaint: jaundice Major Surgical or Invasive Procedure: ERCP w sphincterotomy and stent placement ___ History of Present Illness: Ms. ___ is a ___ female with past medical history of type 2 diabetes, diabetic neuropathy, and hypercholesterolemia who presents with painless jaundice. Patient states that 3 weeks ago she had an acute diarrheal illness with frequent frothy stools lasting for approximately 7 days. Symptoms resolved and patient has been feeling relatively well however ___ days ago has noticed yellowing of her eyes and skin. On questioning has remarked that her urine has been quite dark over the last several weeks as well. Otherwise denies fevers, chills, headache, sore throat, cough, lymph node swelling, chest pain, palpitations, dyspnea, nausea, vomiting, abdominal pain, blood in her stools, dysuria, unusual joint pains or muscle aches, focal weakness. Endorses bilateral lower extremity neuropathy that has been chronic. Estimates that she may have lost approximately 5 pounds in the last week. Past Medical History: # T2DM # Diabetic neuropathy # Hyperlipidemia Social History: ___ Family History: No family history of cancer of liver disease. Physical Exam: ADMISSION EXAM VITALS: ___ Temp: 98.0 PO BP: 129/60 R Sitting HR: 70 RR: 16 O2 sat: 95% O2 delivery: RA GENERAL: Alert and in no apparent distress, markedly jaundiced EYES: Scleral icterus ENT: OP clear with MMMs JVP: Not elevated CV: S1 S2 RRR without audible M/R/G RESP: Lungs clear to auscultation bilaterally without rales or wheeze. GI: Abdomen soft, mildly distended, non-tender to palpation. Bowel sounds present. Palpable liver edge. GU: No suprapubic fullness or tenderness to palpation EXTREM: No edema SKIN: Jaundiced. NEURO: Alert, detailed and fluent historian. No pronator drift. No asterixis. PSYCH: pleasant, appropriate affect ========= DISCHARGE EXAM AVSS pleasant, NAD NCAT, scar over forehead well-healed, mild dysarthria per baseline RRR CTAB sntnd wwp, neg edema jaundice, icteric, subglossal icterus A&O grossly, MAEE, gait wnl, CN II-XII intact except mild scarring effect causing decreased L facial asymmetry on smiling Pertinent Results: ADMISSION RESULTS ___ 02:04PM BLOOD WBC-8.3 RBC-3.30* Hgb-10.1* Hct-30.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-19.9* RDWSD-66.6* Plt ___ ___ 02:04PM BLOOD Neuts-66.8 ___ Monos-7.7 Eos-1.2 Baso-0.2 Im ___ AbsNeut-5.53 AbsLymp-1.91 AbsMono-0.64 AbsEos-0.10 AbsBaso-0.02 ___ 08:50AM BLOOD ___ PTT-32.7 ___ ___ 02:04PM BLOOD Glucose-238* UreaN-14 Creat-0.4 Na-136 K-3.6 Cl-103 HCO3-22 AnGap-11 ___ 02:04PM BLOOD ALT-221* AST-146* AlkPhos-1315* TotBili-13.5* ___ 02:04PM BLOOD Albumin-3.4* ___ 02:04PM BLOOD ___ pO2-59* pCO2-40 pH-7.41 calTCO2-26 Base XS-0 ========== PERTINENT INTERVAL RESULTS ___ BCx NGTD x2 ___ Conclusion: Intrahepatic, extrahepatic Biliary dilatation with distended Courvo___ appearance of gallbladder. Gallbladder contains sludge, no definite stones. Common duct 12.4 mm. 2. No pancreas duct dilatation seen. Pancreas head obscured by gas. Further evaluation of the pancreas with CT recommended. 3. Otherwise Normal ultrasound survey of upper abdomen and retroperitoneum. ERCP: 1.5cm indeterminate stricture at distal CBD, successful ERCP with brushing and biliary stent placement across CBD stricture; biliary duct deeply cannulated with sphincterotome, cannulation moderately difficult, ___ 7cm straight plastic biliary stent placed successfully CTA PANCREAS PROTOCOL: Final Report EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS) INDICATION: ___ year old woman with painless jaundice, head of pancreas obscured on ___ at ___// r/o pancreatic cancer TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.3 s, 47.2 cm; CTDIvol = 18.8 mGy (Body) DLP = 874.5 mGy-cm. Total DLP (Body) = 875 mGy-cm. COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. A biliary stent is in place. There is mild intrahepatic biliary ductal dilatation, and few foci of air within the biliary tree. The common bile duct is dilated, measuring up to 1.3 cm, with abrupt cutoff in the pancreatic head (05:40). Gall bladder is distended. The wall is not thickened. Hyperdense content suggests presence of stones or sludge within the gall bladder lumen. PANCREAS: The pancreatic body and tail are atrophic. The main pancreatic duct is dilated, measuring up to 8 mm, with abrupt cutoff within the pancreatic head (05:36). A side branch in the uncinate process is dilated to 5 mm (05:42). There is a 6 mm hypodensity in the pancreatic head, just anterior to the stent (03:45). No discrete masses visible, but these finding suggest presence of an occult pancreatic masses causing biliary and pancreatic ductal obstruction. There is no peripancreatic stranding. There is no vascular involvement. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are bilateral renal cysts, measuring up to 1.5 cm in the interpolar region of the right kidney and 2.2 cm in the interpolar region of the left kidney, as well as additional bilateral subcentimeter hypodensities too small to characterize by CT. There are also peripheral striations to the nephrogram of each kidney suggesting either acute or chronic parenchymal disease versus fairly uniform bilateral appearance of scarring. There is no renal stenosis. There is no evidence of stones or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. There are few prominent lymph nodes, for example, a hepatic artery lymph node measuring 8 mm (03:30) and a porta hepatis lymph node measuring 8 mm (___:43). PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Calcifications are noted within the uterus, likely representing degenerated fibroids. BONES: There is a mild anterior compression deformity of L2. There are moderate multilevel degenerative changes. No suspicious bone lesions are found. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild intrahepatic biliary dilatation, and dilation of the CBD, with abrupt, within the pancreatic head, with biliary stent in place, as well as dilation of the main pancreatic duct and of a pancreatic side branch in the uncinate process, also with abrupt cutoffs in the pancreatic head. Findings are highly suggestive of an otherwise occult pancreatic head mass. There is no evidence of local invasion or metastatic disease. 2. Mild anterior compression deformity of L2 is likely chronic. ======== DISCHARGE RESULTS ___ 05:40AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.2* Hct-31.3* MCV-93 MCH-30.4 MCHC-32.6 RDW-19.8* RDWSD-67.6* Plt ___ ___ 05:40AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-140 K-3.9 Cl-102 HCO3-24 AnGap-14 ___ 05:40AM BLOOD ALT-204* AST-138* LD(LDH)-152 AlkPhos-1105* TotBili-8.3* ___ 07:21AM BLOOD %HbA1c-6.3* eAG-134* ___ 05:40AM BLOOD CA ___ -PND Brief Hospital Course: ___ w DM, neuropathy p/w painless jaundice and weight loss c/f malignant stricture. ACUTE/ACTIVE PROBLEMS: # Painless jaundice, with ultrasound evidence of intra- and extra-hepatic biliary dilatation, CBD 12.4mm. No signs/symptoms of active cholangitis at this time. Underwent ERCP on ___ with sphincterotomy and stent placement. CTA pancreas obtained with findings concerning for occult pancreatic malignancy. Brushings pending at time of discharge. Pt will be contacted by ___ team with results and if results c/f malignancy, ERCP will arrange outpatient oncology follow up. If brushings are negative (only 60% sensitive in pancreatic malignancy) will need endoscopic ultrasound. Bilirubins improved with above mgmt. with improvement in clinical jaundice. CHRONIC/STABLE PROBLEMS: # T2DM: held home metformin while inpt, continued home humalin (70/30) at 16u qam, 10 qpm per home regimen. A1c 6.8, so decreased home 70/30 insulin to 10u BID. # Diabetic neuropathy: continued home duloxetine, pregabalin # Hyperlipidemia: continued home simvastatin >30 minutes spent on patient care and coordination on day of discharge. TRANSITIONAL ISSUES - biliary brushing cytology results pending at time of discharge; to be followed up by ___ team; if positive, patient will be referred by ___ team to ___ oncology; if negative, patient will require EUS; please ensure this process occurs - please monitor LFTs as outpatient within next week and monitor for resolution of jaundice; if does not resolve, may require further procedures e.g. PTBD versus repeat ERCP - stent placed by ___, removal will be arranged by their service; please ensure patient has follow up scheduled - given A1c 6.8 and age/co-morbidities, decreased insulin to 10U BID from 16 qam /10 qpm - ___ pending at time of discharge; please follow up final result - blood cultures at ___ and ___ pending at time of discharge but do not expect these to be positive; please follow up final results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. DULoxetine 60 mg PO DAILY 4. Pregabalin 50 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 8. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Discharge Medications: 1. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Please now take 10 units twice a day. 2. Aspirin 81 mg PO DAILY 3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 4. DULoxetine 60 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. Pregabalin 50 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: jaundice biliary stricture pancreatic mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ was a pleasure caring for you. You were admitted for yellowing of your eyes and skin ("jaundice"). We believe this was caused by a mass in your pancreas leading to a blockage in your bile ducts. We are concerned this mass is a cancer, but we are awaiting test results. You will be contacted with the results of the brushings and will make a plan with the ERCP doctors for follow up, including when to replace your stent as an outpatient. Please contact your PCP and have your labs checked again in the next week to ensure the jaundice is continuing to resolve. We also decreased your insulin because your sugars were a little more tightly controlled than necessary. We wish you the best in your recovery! Followup Instructions: ___
[ "K831", "C250", "E1140", "E785", "Z7984", "Z794", "Z87891" ]
Allergies: penicillin Chief Complaint: jaundice Major Surgical or Invasive Procedure: ERCP w sphincterotomy and stent placement [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] female with past medical history of type 2 diabetes, diabetic neuropathy, and hypercholesterolemia who presents with painless jaundice. Patient states that 3 weeks ago she had an acute diarrheal illness with frequent frothy stools lasting for approximately 7 days. Symptoms resolved and patient has been feeling relatively well however [MASKED] days ago has noticed yellowing of her eyes and skin. On questioning has remarked that her urine has been quite dark over the last several weeks as well. Otherwise denies fevers, chills, headache, sore throat, cough, lymph node swelling, chest pain, palpitations, dyspnea, nausea, vomiting, abdominal pain, blood in her stools, dysuria, unusual joint pains or muscle aches, focal weakness. Endorses bilateral lower extremity neuropathy that has been chronic. Estimates that she may have lost approximately 5 pounds in the last week. Past Medical History: # T2DM # Diabetic neuropathy # Hyperlipidemia Social History: [MASKED] Family History: No family history of cancer of liver disease. Physical Exam: ADMISSION EXAM VITALS: [MASKED] Temp: 98.0 PO BP: 129/60 R Sitting HR: 70 RR: 16 O2 sat: 95% O2 delivery: RA GENERAL: Alert and in no apparent distress, markedly jaundiced EYES: Scleral icterus ENT: OP clear with MMMs JVP: Not elevated CV: S1 S2 RRR without audible M/R/G RESP: Lungs clear to auscultation bilaterally without rales or wheeze. GI: Abdomen soft, mildly distended, non-tender to palpation. Bowel sounds present. Palpable liver edge. GU: No suprapubic fullness or tenderness to palpation EXTREM: No edema SKIN: Jaundiced. NEURO: Alert, detailed and fluent historian. No pronator drift. No asterixis. PSYCH: pleasant, appropriate affect ========= DISCHARGE EXAM AVSS pleasant, NAD NCAT, scar over forehead well-healed, mild dysarthria per baseline RRR CTAB sntnd wwp, neg edema jaundice, icteric, subglossal icterus A&O grossly, MAEE, gait wnl, CN II-XII intact except mild scarring effect causing decreased L facial asymmetry on smiling Pertinent Results: ADMISSION RESULTS [MASKED] 02:04PM BLOOD WBC-8.3 RBC-3.30* Hgb-10.1* Hct-30.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-19.9* RDWSD-66.6* Plt [MASKED] [MASKED] 02:04PM BLOOD Neuts-66.8 [MASKED] Monos-7.7 Eos-1.2 Baso-0.2 Im [MASKED] AbsNeut-5.53 AbsLymp-1.91 AbsMono-0.64 AbsEos-0.10 AbsBaso-0.02 [MASKED] 08:50AM BLOOD [MASKED] PTT-32.7 [MASKED] [MASKED] 02:04PM BLOOD Glucose-238* UreaN-14 Creat-0.4 Na-136 K-3.6 Cl-103 HCO3-22 AnGap-11 [MASKED] 02:04PM BLOOD ALT-221* AST-146* AlkPhos-1315* TotBili-13.5* [MASKED] 02:04PM BLOOD Albumin-3.4* [MASKED] 02:04PM BLOOD [MASKED] pO2-59* pCO2-40 pH-7.41 calTCO2-26 Base XS-0 ========== PERTINENT INTERVAL RESULTS [MASKED] BCx NGTD x2 [MASKED] Conclusion: Intrahepatic, extrahepatic Biliary dilatation with distended Courvo appearance of gallbladder. Gallbladder contains sludge, no definite stones. Common duct 12.4 mm. 2. No pancreas duct dilatation seen. Pancreas head obscured by gas. Further evaluation of the pancreas with CT recommended. 3. Otherwise Normal ultrasound survey of upper abdomen and retroperitoneum. ERCP: 1.5cm indeterminate stricture at distal CBD, successful ERCP with brushing and biliary stent placement across CBD stricture; biliary duct deeply cannulated with sphincterotome, cannulation moderately difficult, [MASKED] 7cm straight plastic biliary stent placed successfully CTA PANCREAS PROTOCOL: Final Report EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS) INDICATION: [MASKED] year old woman with painless jaundice, head of pancreas obscured on [MASKED] at [MASKED]// r/o pancreatic cancer TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.3 s, 47.2 cm; CTDIvol = 18.8 mGy (Body) DLP = 874.5 mGy-cm. Total DLP (Body) = 875 mGy-cm. COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. A biliary stent is in place. There is mild intrahepatic biliary ductal dilatation, and few foci of air within the biliary tree. The common bile duct is dilated, measuring up to 1.3 cm, with abrupt cutoff in the pancreatic head (05:40). Gall bladder is distended. The wall is not thickened. Hyperdense content suggests presence of stones or sludge within the gall bladder lumen. PANCREAS: The pancreatic body and tail are atrophic. The main pancreatic duct is dilated, measuring up to 8 mm, with abrupt cutoff within the pancreatic head (05:36). A side branch in the uncinate process is dilated to 5 mm (05:42). There is a 6 mm hypodensity in the pancreatic head, just anterior to the stent (03:45). No discrete masses visible, but these finding suggest presence of an occult pancreatic masses causing biliary and pancreatic ductal obstruction. There is no peripancreatic stranding. There is no vascular involvement. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are bilateral renal cysts, measuring up to 1.5 cm in the interpolar region of the right kidney and 2.2 cm in the interpolar region of the left kidney, as well as additional bilateral subcentimeter hypodensities too small to characterize by CT. There are also peripheral striations to the nephrogram of each kidney suggesting either acute or chronic parenchymal disease versus fairly uniform bilateral appearance of scarring. There is no renal stenosis. There is no evidence of stones or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. There are few prominent lymph nodes, for example, a hepatic artery lymph node measuring 8 mm (03:30) and a porta hepatis lymph node measuring 8 mm ([MASKED]:43). PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Calcifications are noted within the uterus, likely representing degenerated fibroids. BONES: There is a mild anterior compression deformity of L2. There are moderate multilevel degenerative changes. No suspicious bone lesions are found. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild intrahepatic biliary dilatation, and dilation of the CBD, with abrupt, within the pancreatic head, with biliary stent in place, as well as dilation of the main pancreatic duct and of a pancreatic side branch in the uncinate process, also with abrupt cutoffs in the pancreatic head. Findings are highly suggestive of an otherwise occult pancreatic head mass. There is no evidence of local invasion or metastatic disease. 2. Mild anterior compression deformity of L2 is likely chronic. ======== DISCHARGE RESULTS [MASKED] 05:40AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.2* Hct-31.3* MCV-93 MCH-30.4 MCHC-32.6 RDW-19.8* RDWSD-67.6* Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-140 K-3.9 Cl-102 HCO3-24 AnGap-14 [MASKED] 05:40AM BLOOD ALT-204* AST-138* LD(LDH)-152 AlkPhos-1105* TotBili-8.3* [MASKED] 07:21AM BLOOD %HbA1c-6.3* eAG-134* [MASKED] 05:40AM BLOOD CA [MASKED] -PND Brief Hospital Course: [MASKED] w DM, neuropathy p/w painless jaundice and weight loss c/f malignant stricture. ACUTE/ACTIVE PROBLEMS: # Painless jaundice, with ultrasound evidence of intra- and extra-hepatic biliary dilatation, CBD 12.4mm. No signs/symptoms of active cholangitis at this time. Underwent ERCP on [MASKED] with sphincterotomy and stent placement. CTA pancreas obtained with findings concerning for occult pancreatic malignancy. Brushings pending at time of discharge. Pt will be contacted by [MASKED] team with results and if results c/f malignancy, ERCP will arrange outpatient oncology follow up. If brushings are negative (only 60% sensitive in pancreatic malignancy) will need endoscopic ultrasound. Bilirubins improved with above mgmt. with improvement in clinical jaundice. CHRONIC/STABLE PROBLEMS: # T2DM: held home metformin while inpt, continued home humalin (70/30) at 16u qam, 10 qpm per home regimen. A1c 6.8, so decreased home 70/30 insulin to 10u BID. # Diabetic neuropathy: continued home duloxetine, pregabalin # Hyperlipidemia: continued home simvastatin >30 minutes spent on patient care and coordination on day of discharge. TRANSITIONAL ISSUES - biliary brushing cytology results pending at time of discharge; to be followed up by [MASKED] team; if positive, patient will be referred by [MASKED] team to [MASKED] oncology; if negative, patient will require EUS; please ensure this process occurs - please monitor LFTs as outpatient within next week and monitor for resolution of jaundice; if does not resolve, may require further procedures e.g. PTBD versus repeat ERCP - stent placed by [MASKED], removal will be arranged by their service; please ensure patient has follow up scheduled - given A1c 6.8 and age/co-morbidities, decreased insulin to 10U BID from 16 qam /10 qpm - [MASKED] pending at time of discharge; please follow up final result - blood cultures at [MASKED] and [MASKED] pending at time of discharge but do not expect these to be positive; please follow up final results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. DULoxetine 60 mg PO DAILY 4. Pregabalin 50 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 8. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Discharge Medications: 1. NovoLIN [MASKED] FlexPen U-100 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Please now take 10 units twice a day. 2. Aspirin 81 mg PO DAILY 3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 4. DULoxetine 60 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. Pregabalin 50 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: jaundice biliary stricture pancreatic mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED] was a pleasure caring for you. You were admitted for yellowing of your eyes and skin ("jaundice"). We believe this was caused by a mass in your pancreas leading to a blockage in your bile ducts. We are concerned this mass is a cancer, but we are awaiting test results. You will be contacted with the results of the brushings and will make a plan with the ERCP doctors for follow up, including when to replace your stent as an outpatient. Please contact your PCP and have your labs checked again in the next week to ensure the jaundice is continuing to resolve. We also decreased your insulin because your sugars were a little more tightly controlled than necessary. We wish you the best in your recovery! Followup Instructions: [MASKED]
[]
[ "E785", "Z794", "Z87891" ]
[ "K831: Obstruction of bile duct", "C250: Malignant neoplasm of head of pancreas", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E785: Hyperlipidemia, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]
10,053,184
25,990,123
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ciprofloxacin Attending: ___. Chief Complaint: Cough, rhoncherous breathing Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old with history of advanced dementia (bed bound, non-vocal, rarely opens eyes to voice for past few months) and seizure disorder presenting with cough and rhoncherous breathing. Per reports, pt was noted to have developed a cough starting on ___ night. Her cough persisted, and on ___ she developed a worsening cough with rhoncherous breathing. Given her worsening symptoms, pt's PCP, ___, was called and referral to the ___ to rule out pneumonia was recommended. Of note, pt is taken care of at home by two home health aids, one of which was recently exposed to an ILI. In the ___, initial vital signs were: 100.2 93 ___ 100% RA - Exam was notable for: Pt arousable to painful stimuli (baseline she is arousable to voice), diffuse rhonchi are symmetric and likely transmitted upper airway sounds, no unilateral ___ edema - Labs were notable for: WBC 6.6, H/H 15.4/46.2, plts 111, NA 137, K 4.5, BUN/Cr ___, LFTs WNL, alb 2.9, INR 1.0, proBNP 378, troponin 0.04, lactate 3.3 - UA with 11 WBC, many bacteria, positive nitrites, small leuks, <1 epis - Flu A and B PCR negative - Imaging: CXR with no acute intrathoracic process - The patient was given: 2L NS, Azithromycin 500mg IV x 1 - Consults: None Vitals prior to transfer were: 98.5 84 103/65 26 100% RA Upon arrival to the floor, pt is at her baseline and unresponsive. REVIEW OF SYSTEMS: Negative except as above. Past Medical History: ACUTE BRONCHITIS ANXIETY ASTHMA DEMENTIA LEFT BUNDLE BRANCH BLOCK URINARY TRACT INFECTION OTALGIA SKIN ULCERS Social History: ___ Family History: No family history of early dementia Physical Exam: ================================= EXAM ON ADMISSION ================================= VITALS - 98.2 104/63 75 18 95% on RA GENERAL - Unresponsive, eventually opened eyes to sternal rub HEENT - normocephalic, atraumatic, PERRLA NECK - supple CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - Rhoncherous upper airway sounds ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - Eventually opens eyes to sternal rub ================================= EXAM ON DISCHARGE ================================= VITALS - 98.2, 85, 133/83, 18, 95%RA GENERAL - At times opens eyes to voice, otherwise nonverbal and nonresponsive CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - breathing is even and unlabored, breath sounds less rhoncherous. Coughing at times Pertinent Results: ============================= LABS ON ADMISSION ============================= ___ 05:25PM BLOOD WBC-6.6 RBC-4.38 Hgb-15.4 Hct-46.2* MCV-106*# MCH-35.2*# MCHC-33.3 RDW-14.7 RDWSD-58.3* Plt ___ ___ 05:25PM BLOOD Neuts-52.1 ___ Monos-23.4* Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.46 AbsLymp-1.57 AbsMono-1.55* AbsEos-0.00* AbsBaso-0.01 ___ 05:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 05:25PM BLOOD ___ PTT-25.2 ___ ___ 05:25PM BLOOD Glucose-139* UreaN-22* Creat-0.5 Na-137 K-4.5 Cl-100 HCO3-26 AnGap-16 ___ 05:25PM BLOOD ALT-22 AST-33 AlkPhos-71 TotBili-0.3 ___ 05:25PM BLOOD proBNP-378* ___ 05:25PM BLOOD cTropnT-0.04* ___ 06:30AM BLOOD CK-MB-4 cTropnT-0.03* ___ 05:25PM BLOOD Albumin-2.9* ___ 06:30AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9 ___ 05:31PM BLOOD Lactate-3.3* ___ 11:50PM BLOOD Lactate-2.8* ============================= LABS ON DISCHARGE ============================= ___ 06:30AM BLOOD WBC-6.1 RBC-3.84* Hgb-13.5 Hct-41.3 MCV-108* MCH-35.2* MCHC-32.7 RDW-14.9 RDWSD-59.1* Plt Ct-92* ___ 06:30AM BLOOD Glucose-81 UreaN-19 Creat-0.4 Na-138 K-4.3 Cl-107 HCO3-24 AnGap-11 ============================= MICROBIOLOGY ============================= ___ Blood cultures - NGTD ___ Urine culture - Klebsiella AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ============================= IMAGING/STUDIES ============================= ___ CXR - AP portable upright view of the chest. Overlying EKG leads are present. Mildly elevated right hemidiaphragm again noted. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. Brief Hospital Course: ___ year old female with advanced Alzheimer's dementia, seizure disorder, and asthma presenting with cough and rhoncherous breathing, found to have likely UTI and possible URI. # Presumed UTI and possible URI: The patient was found to have a positive UA and an elevated lactate making UTI as the most likely etiology of her encephalopathy. She was started on ceftriaxone for treatment. Her CXR did not demonstrate evidence of pneumonia. however she was found to have notable rhonchi on exam with secretions suggestive of URI/bronchitis. Given her clinical picture, she was also started on a course of azithromycin. Her lactate began to downtrend, and her mental status improved with treatment with the antibiotics. Following a discussion about hospice care (see below), the patient was discharged home to complete a five day course of augmentin and azithromycin to complete her treatment. # Advanced dementia/Goals of care: Pt has rapidly declined over the past ___ months and is currently bed bound and unresponsive at baseline. The patient was made DNR/DNI on admission. Her husband expressed interest in hospice care. The patient currently has two home aids. However, neither are trained in medical care. Palliative care was consulted, after a discussion it was decided that the patient would have home hospice care. Discussed with husband at length the course of end-stage dementia, and how it is a uniformly fatal disease. Discussed possible difficulties he and his family may encounter, including difficulty with nutrition and hydration and recurrent infections. Reviewed MOLST form with husband. Patient will be DNR/DNI with transfer to hospital only for comfort. # Seizure disorder: Pt has a history of generalized seizure in the setting of advanced dementia. Continued home divalproex. TRANSITIONAL ISSUES: [] patient was discharged to complete a 5 day course of azithromycin and augmentin for UTI and pneumonia. [] patient was discharged home with hospice, and focus is to be on comfort [] will plan to continue divalproex sprinkles to prevent seizures. The need for this can be further discussed with the patient's outpatient providers. # CONTACT: ___ (Husband/HCP) ___ # CODE STATUS: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex Sod. Sprinkles 750 mg PO BID 2. Bismuth Subsalicylate 15 mL PO TID:PRN Indigestion 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 5. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: ___, First Dose: Next Routine Administration Time Discharge Medications: 1. Divalproex Sod. Sprinkles 750 mg PO BID 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q12H RX *amoxicillin-pot clavulanate 250 mg-62.5 mg/5 mL 10 mL by mouth twice a day Refills:*0 4. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 5. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 6. Bismuth Subsalicylate 15 mL PO TID:PRN Indigestion Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: - urinary tract infection - upper respiratory infection - end-stage dementia Secondary Diagnoses - skin ulcers - anorexia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___ and family, You were admitted with a cough and difficulty breathing, and we also found that you have an infection in your urine. We treated you with antibiotics. We also discussed helping with your care at home, including hospice. We hope that these services help with keeping you comfortable at home with your family. We wish you and your family all the best. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "N390", "L89152", "I248", "G309", "G40409", "L89621", "R630", "F0280", "J069", "F419", "J45909", "I447", "Z6823", "Z515", "Z66" ]
Allergies: Ciprofloxacin Chief Complaint: Cough, rhoncherous breathing Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old with history of advanced dementia (bed bound, non-vocal, rarely opens eyes to voice for past few months) and seizure disorder presenting with cough and rhoncherous breathing. Per reports, pt was noted to have developed a cough starting on [MASKED] night. Her cough persisted, and on [MASKED] she developed a worsening cough with rhoncherous breathing. Given her worsening symptoms, pt's PCP, [MASKED], was called and referral to the [MASKED] to rule out pneumonia was recommended. Of note, pt is taken care of at home by two home health aids, one of which was recently exposed to an ILI. In the [MASKED], initial vital signs were: 100.2 93 [MASKED] 100% RA - Exam was notable for: Pt arousable to painful stimuli (baseline she is arousable to voice), diffuse rhonchi are symmetric and likely transmitted upper airway sounds, no unilateral [MASKED] edema - Labs were notable for: WBC 6.6, H/H 15.4/46.2, plts 111, NA 137, K 4.5, BUN/Cr [MASKED], LFTs WNL, alb 2.9, INR 1.0, proBNP 378, troponin 0.04, lactate 3.3 - UA with 11 WBC, many bacteria, positive nitrites, small leuks, <1 epis - Flu A and B PCR negative - Imaging: CXR with no acute intrathoracic process - The patient was given: 2L NS, Azithromycin 500mg IV x 1 - Consults: None Vitals prior to transfer were: 98.5 84 103/65 26 100% RA Upon arrival to the floor, pt is at her baseline and unresponsive. REVIEW OF SYSTEMS: Negative except as above. Past Medical History: ACUTE BRONCHITIS ANXIETY ASTHMA DEMENTIA LEFT BUNDLE BRANCH BLOCK URINARY TRACT INFECTION OTALGIA SKIN ULCERS Social History: [MASKED] Family History: No family history of early dementia Physical Exam: ================================= EXAM ON ADMISSION ================================= VITALS - 98.2 104/63 75 18 95% on RA GENERAL - Unresponsive, eventually opened eyes to sternal rub HEENT - normocephalic, atraumatic, PERRLA NECK - supple CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - Rhoncherous upper airway sounds ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - Eventually opens eyes to sternal rub ================================= EXAM ON DISCHARGE ================================= VITALS - 98.2, 85, 133/83, 18, 95%RA GENERAL - At times opens eyes to voice, otherwise nonverbal and nonresponsive CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - breathing is even and unlabored, breath sounds less rhoncherous. Coughing at times Pertinent Results: ============================= LABS ON ADMISSION ============================= [MASKED] 05:25PM BLOOD WBC-6.6 RBC-4.38 Hgb-15.4 Hct-46.2* MCV-106*# MCH-35.2*# MCHC-33.3 RDW-14.7 RDWSD-58.3* Plt [MASKED] [MASKED] 05:25PM BLOOD Neuts-52.1 [MASKED] Monos-23.4* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-3.46 AbsLymp-1.57 AbsMono-1.55* AbsEos-0.00* AbsBaso-0.01 [MASKED] 05:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [MASKED] 05:25PM BLOOD [MASKED] PTT-25.2 [MASKED] [MASKED] 05:25PM BLOOD Glucose-139* UreaN-22* Creat-0.5 Na-137 K-4.5 Cl-100 HCO3-26 AnGap-16 [MASKED] 05:25PM BLOOD ALT-22 AST-33 AlkPhos-71 TotBili-0.3 [MASKED] 05:25PM BLOOD proBNP-378* [MASKED] 05:25PM BLOOD cTropnT-0.04* [MASKED] 06:30AM BLOOD CK-MB-4 cTropnT-0.03* [MASKED] 05:25PM BLOOD Albumin-2.9* [MASKED] 06:30AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9 [MASKED] 05:31PM BLOOD Lactate-3.3* [MASKED] 11:50PM BLOOD Lactate-2.8* ============================= LABS ON DISCHARGE ============================= [MASKED] 06:30AM BLOOD WBC-6.1 RBC-3.84* Hgb-13.5 Hct-41.3 MCV-108* MCH-35.2* MCHC-32.7 RDW-14.9 RDWSD-59.1* Plt Ct-92* [MASKED] 06:30AM BLOOD Glucose-81 UreaN-19 Creat-0.4 Na-138 K-4.3 Cl-107 HCO3-24 AnGap-11 ============================= MICROBIOLOGY ============================= [MASKED] Blood cultures - NGTD [MASKED] Urine culture - Klebsiella AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ============================= IMAGING/STUDIES ============================= [MASKED] CXR - AP portable upright view of the chest. Overlying EKG leads are present. Mildly elevated right hemidiaphragm again noted. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. Brief Hospital Course: [MASKED] year old female with advanced Alzheimer's dementia, seizure disorder, and asthma presenting with cough and rhoncherous breathing, found to have likely UTI and possible URI. # Presumed UTI and possible URI: The patient was found to have a positive UA and an elevated lactate making UTI as the most likely etiology of her encephalopathy. She was started on ceftriaxone for treatment. Her CXR did not demonstrate evidence of pneumonia. however she was found to have notable rhonchi on exam with secretions suggestive of URI/bronchitis. Given her clinical picture, she was also started on a course of azithromycin. Her lactate began to downtrend, and her mental status improved with treatment with the antibiotics. Following a discussion about hospice care (see below), the patient was discharged home to complete a five day course of augmentin and azithromycin to complete her treatment. # Advanced dementia/Goals of care: Pt has rapidly declined over the past [MASKED] months and is currently bed bound and unresponsive at baseline. The patient was made DNR/DNI on admission. Her husband expressed interest in hospice care. The patient currently has two home aids. However, neither are trained in medical care. Palliative care was consulted, after a discussion it was decided that the patient would have home hospice care. Discussed with husband at length the course of end-stage dementia, and how it is a uniformly fatal disease. Discussed possible difficulties he and his family may encounter, including difficulty with nutrition and hydration and recurrent infections. Reviewed MOLST form with husband. Patient will be DNR/DNI with transfer to hospital only for comfort. # Seizure disorder: Pt has a history of generalized seizure in the setting of advanced dementia. Continued home divalproex. TRANSITIONAL ISSUES: [] patient was discharged to complete a 5 day course of azithromycin and augmentin for UTI and pneumonia. [] patient was discharged home with hospice, and focus is to be on comfort [] will plan to continue divalproex sprinkles to prevent seizures. The need for this can be further discussed with the patient's outpatient providers. # CONTACT: [MASKED] (Husband/HCP) [MASKED] # CODE STATUS: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex Sod. Sprinkles 750 mg PO BID 2. Bismuth Subsalicylate 15 mL PO TID:PRN Indigestion 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 5. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: [MASKED], First Dose: Next Routine Administration Time Discharge Medications: 1. Divalproex Sod. Sprinkles 750 mg PO BID 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q12H RX *amoxicillin-pot clavulanate 250 mg-62.5 mg/5 mL 10 mL by mouth twice a day Refills:*0 4. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 5. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 6. Bismuth Subsalicylate 15 mL PO TID:PRN Indigestion Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnoses: - urinary tract infection - upper respiratory infection - end-stage dementia Secondary Diagnoses - skin ulcers - anorexia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [MASKED] and family, You were admitted with a cough and difficulty breathing, and we also found that you have an infection in your urine. We treated you with antibiotics. We also discussed helping with your care at home, including hospice. We hope that these services help with keeping you comfortable at home with your family. We wish you and your family all the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N390", "F419", "J45909", "Z515", "Z66" ]
[ "N390: Urinary tract infection, site not specified", "L89152: Pressure ulcer of sacral region, stage 2", "I248: Other forms of acute ischemic heart disease", "G309: Alzheimer's disease, unspecified", "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "L89621: Pressure ulcer of left heel, stage 1", "R630: Anorexia", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "J069: Acute upper respiratory infection, unspecified", "F419: Anxiety disorder, unspecified", "J45909: Unspecified asthma, uncomplicated", "I447: Left bundle-branch block, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "Z515: Encounter for palliative care", "Z66: Do not resuscitate" ]
10,053,216
22,569,760
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: codeine / tetracycline Attending: ___. Chief Complaint: Polycystic Liver disease with multiple liver cysts with dominant cysts in right lobe. Major Surgical or Invasive Procedure: Laparoscopic cyst unroofing History of Present Illness: ___ year old female with chief complaint of abdominal pain on her right side rated ___ since last night. States sudden onset, worse with heaving breathing and movement. States pain decreases when lying down. She is scheduled for unroofing of hepatic cysts by Dr. ___. Per ___, she had a large dominant cyst in the right lobe of the liver just under 20 cm with some smaller ones on the left. At that point, she was asymptomatic. However, since that visit, she has developed increasing sharp pain in the epigastric area with fullness and would now like to proceed with cyst fenestration. Denies any F/C/N/V, no other GI, GU complaints, on Tylenol and Gabapentin, no neuro changes, no jaundice. Past Medical History: PMH:asthma, GERD, osteopenia, knee osteoarthritis, stable lung nodule and history of colonic polyps PSH:C-sections x 2, cystoscopy, bunionectomy and arthroplasty of right Social History: ___ Family History: No family history of liver disease Physical Exam: VS: 98.7, 80, 91/49, 18, 94% RA General: AAOx3, NAD Cardiac: RRR Resp: CTA b/l Abdomen: soft, non distended, tender RUQ Extremities: no calf tenderness, no cyanosis or edema Pertinent Results: Pre-op: ___ WBC-6.3 RBC-4.43 Hgb-13.2 Hct-40.1 MCV-91 MCH-29.8 MCHC-32.9 RDW-13.2 RDWSD-43.6 Plt ___ PTT-35.2 ___ Glucose-95 UreaN-13 Creat-0.7 Na-140 K-3.8 Cl-104 HCO3-24 AnGap-16 ALT-21 AST-23 AlkPhos-151* TotBili-0.7 Lipase-23 Albumin-4.5 Calcium-9.7 Phos-2.9 Mg-2.0 Lactate-1.3 . Labs at Discharge: ___ WBC-5.4 RBC-3.64* Hgb-10.4* Hct-33.8* MCV-93 MCH-28.6 MCHC-30.8* RDW-13.1 RDWSD-44.3 Plt ___ Glucose-105* UreaN-12 Creat-0.6 Na-138 K-3.8 Cl-103 HCO3-28 AnGap-11 ALT-58* AST-50* AlkPhos-119* TotBili-0.3 Calcium-8.6 Phos-3.8 Mg-2.___ year old female admitted through the ED with symptomatic abdominal pain. She has been scheduled for cyst unroofing with Dr ___ on ___ but the pain has increased, and so she is admitted with anticipated OR date still on ___. Patient was taken to the OR as planned with Dr ___ on ___ for planned cyst unroofing. In the OR the cyst was opened and drained of about 3.5 L of chocolate colored fluid from the cyst. The exophytic portion of the cyst wall was then excised and submitted to pathology. A JP drain was placed into the cyst bed, and the patient was then closed, extubated and transferred to the PACU in stable condition. Following the surgery, the patient had a significant decrease in the presenting abdominal pain. Over the course of the next ___ hours, her diet was slowly advanced and she was tolerating diet with some mild nausea, attributed to narcotics which was changed to Tramadol with better tolerance. LFTs were monitored and took a slight bump, with normal T Bili and alk phos. JP drain was draining increasingly clearer drainage about 120 cc prior to discharge. Patient was discharged with the JP drain. Incisions were clean dry and intact. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 100 mg PO QHS 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. biotin 2,500 mcg oral DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit) 500-400 mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain Maximum 8 of the 325 mg tablets daily 2. Docusate Sodium 100 mg PO BID ___ purchase over the counter RX *docusate sodium [Doc-Q-Lace] 100 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills:*0 3. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain RX *tramadol 50 mg 1 tablet(s) by mouth q 4 hours Disp #*30 Tablet Refills:*0 4. biotin 2,500 mcg oral DAILY 5. Gabapentin 100 mg PO QHS 6. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit) 500-400 mg oral DAILY 7. Vitamin D ___ UNIT PO DAILY 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 Tablet by mouth twice a day Disp #*24 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Polycystic Liver Disease with Multiple liver cysts with dominant cysts in right lobe. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ Care Network has been arranged for discharge to home with services Please call Dr. ___ office at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, the incision sites have redness, drainage or bleeding, or any other concerning symptoms. You may shower. Allow water to run over the incision sites. Do not apply lotions or powders to the incision areas. Leave incisions open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication You are being discharged with the JP drain in place. Drain and record the JP drain output twice daily and as needed so that the drain is never more than ½ full. Call the office if the drain output increases by more than 100 cc from the previous day, turns greenish in color, becomes bloody or develops a foul odor. Change the drain dressing once daily or after your shower. Do not allow the drain to hang freely at any time. Inspect the site for redness, drainage or bleeding. Make sure there is a stitch at the drain site. Followup Instructions: ___
[ "Q446", "M170", "M85862", "M85861" ]
Allergies: codeine / tetracycline Chief Complaint: Polycystic Liver disease with multiple liver cysts with dominant cysts in right lobe. Major Surgical or Invasive Procedure: Laparoscopic cyst unroofing History of Present Illness: [MASKED] year old female with chief complaint of abdominal pain on her right side rated [MASKED] since last night. States sudden onset, worse with heaving breathing and movement. States pain decreases when lying down. She is scheduled for unroofing of hepatic cysts by Dr. [MASKED]. Per [MASKED], she had a large dominant cyst in the right lobe of the liver just under 20 cm with some smaller ones on the left. At that point, she was asymptomatic. However, since that visit, she has developed increasing sharp pain in the epigastric area with fullness and would now like to proceed with cyst fenestration. Denies any F/C/N/V, no other GI, GU complaints, on Tylenol and Gabapentin, no neuro changes, no jaundice. Past Medical History: PMH:asthma, GERD, osteopenia, knee osteoarthritis, stable lung nodule and history of colonic polyps PSH:C-sections x 2, cystoscopy, bunionectomy and arthroplasty of right Social History: [MASKED] Family History: No family history of liver disease Physical Exam: VS: 98.7, 80, 91/49, 18, 94% RA General: AAOx3, NAD Cardiac: RRR Resp: CTA b/l Abdomen: soft, non distended, tender RUQ Extremities: no calf tenderness, no cyanosis or edema Pertinent Results: Pre-op: [MASKED] WBC-6.3 RBC-4.43 Hgb-13.2 Hct-40.1 MCV-91 MCH-29.8 MCHC-32.9 RDW-13.2 RDWSD-43.6 Plt [MASKED] PTT-35.2 [MASKED] Glucose-95 UreaN-13 Creat-0.7 Na-140 K-3.8 Cl-104 HCO3-24 AnGap-16 ALT-21 AST-23 AlkPhos-151* TotBili-0.7 Lipase-23 Albumin-4.5 Calcium-9.7 Phos-2.9 Mg-2.0 Lactate-1.3 . Labs at Discharge: [MASKED] WBC-5.4 RBC-3.64* Hgb-10.4* Hct-33.8* MCV-93 MCH-28.6 MCHC-30.8* RDW-13.1 RDWSD-44.3 Plt [MASKED] Glucose-105* UreaN-12 Creat-0.6 Na-138 K-3.8 Cl-103 HCO3-28 AnGap-11 ALT-58* AST-50* AlkPhos-119* TotBili-0.3 Calcium-8.6 Phos-3.8 Mg-2.[MASKED] year old female admitted through the ED with symptomatic abdominal pain. She has been scheduled for cyst unroofing with Dr [MASKED] on [MASKED] but the pain has increased, and so she is admitted with anticipated OR date still on [MASKED]. Patient was taken to the OR as planned with Dr [MASKED] on [MASKED] for planned cyst unroofing. In the OR the cyst was opened and drained of about 3.5 L of chocolate colored fluid from the cyst. The exophytic portion of the cyst wall was then excised and submitted to pathology. A JP drain was placed into the cyst bed, and the patient was then closed, extubated and transferred to the PACU in stable condition. Following the surgery, the patient had a significant decrease in the presenting abdominal pain. Over the course of the next [MASKED] hours, her diet was slowly advanced and she was tolerating diet with some mild nausea, attributed to narcotics which was changed to Tramadol with better tolerance. LFTs were monitored and took a slight bump, with normal T Bili and alk phos. JP drain was draining increasingly clearer drainage about 120 cc prior to discharge. Patient was discharged with the JP drain. Incisions were clean dry and intact. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 100 mg PO QHS 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. biotin 2,500 mcg oral DAILY 4. Vitamin D [MASKED] UNIT PO DAILY 5. Glucosamine Sulf-Chondroitin (glucosamine [MASKED] 2KCl-chondroit) 500-400 mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain Maximum 8 of the 325 mg tablets daily 2. Docusate Sodium 100 mg PO BID [MASKED] purchase over the counter RX *docusate sodium [Doc-Q-Lace] 100 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills:*0 3. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain RX *tramadol 50 mg 1 tablet(s) by mouth q 4 hours Disp #*30 Tablet Refills:*0 4. biotin 2,500 mcg oral DAILY 5. Gabapentin 100 mg PO QHS 6. Glucosamine Sulf-Chondroitin (glucosamine [MASKED] 2KCl-chondroit) 500-400 mg oral DAILY 7. Vitamin D [MASKED] UNIT PO DAILY 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 Tablet by mouth twice a day Disp #*24 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Polycystic Liver Disease with Multiple liver cysts with dominant cysts in right lobe. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED] Care Network has been arranged for discharge to home with services Please call Dr. [MASKED] office at [MASKED] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, the incision sites have redness, drainage or bleeding, or any other concerning symptoms. You may shower. Allow water to run over the incision sites. Do not apply lotions or powders to the incision areas. Leave incisions open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication You are being discharged with the JP drain in place. Drain and record the JP drain output twice daily and as needed so that the drain is never more than ½ full. Call the office if the drain output increases by more than 100 cc from the previous day, turns greenish in color, becomes bloody or develops a foul odor. Change the drain dressing once daily or after your shower. Do not allow the drain to hang freely at any time. Inspect the site for redness, drainage or bleeding. Make sure there is a stitch at the drain site. Followup Instructions: [MASKED]
[]
[]
[ "Q446: Cystic disease of liver", "M170: Bilateral primary osteoarthritis of knee", "M85862: Other specified disorders of bone density and structure, left lower leg", "M85861: Other specified disorders of bone density and structure, right lower leg" ]
10,053,697
25,563,287
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: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ ___ yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0 at 33w3d presented to ___ for evaluation after fall. HPI: She was walking her dog this morning with a hot cocoa in her hand and tripped over uneven sidewalk. She landed on her right hand, right wrist and flank. She is not sure if she hit her abdomen, but doesn't think so. She was seen in ER and diagnosed with Boxer's fracture of ___ metacarpal. Her hand was splinted and she was transferred to L and D for further evaluation. She denies ctx, LOF, VB, abdominal pain. +FM. Past Medical History: PMH: ADHD PSH: Wisdom teeth removal Social History: ___ Family History: Non-contributory. Physical Exam: On admission: VSS Constitutional: Gravid well developed, well nourished female, appearing in no acute distress Abdomen: no tenderness and no masses Fundus: size equals dates, nontender and not irritable EFW:Average Sterile speculum exam: Dilation: Closed Effacement: Long Extremity: Hand wrapped per ortho Pertinent Results: ___ 01:04PM FETAL HGB-0 ___ 01:02PM WBC-10.1* RBC-3.67* HGB-12.0 HCT-35.3 MCV-96 MCH-32.7* MCHC-34.0 RDW-13.1 RDWSD-46.1 ___ 01:02PM PLT COUNT-191 ___ 01:02PM ___ PTT-27.2 ___ ___ 01:02PM ___ Brief Hospital Course: Ms. ___ was transferred from the ED to Labor and Delivery. Given significant fall and ongoing contractions, decision made to monitor x 24 hours on L&D. This was uneventful. At the end of this period, she was discharged home with close OB and ortho follow-up. Medications on Admission: PNV Discharge Medications: PNV Discharge Disposition: Home Discharge Diagnosis: Right hand fracture Pregnancy at 33 weeks Discharge Condition: Stable Discharge Instructions: Please keep appointments with Dr. ___ orthopedics as scheduled. Followup Instructions: ___
[ "O9A213", "S62336A", "O4443", "O99343", "F909", "Z3A33", "W1839XA", "Y9289" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] [MASKED] yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0 at 33w3d presented to [MASKED] for evaluation after fall. HPI: She was walking her dog this morning with a hot cocoa in her hand and tripped over uneven sidewalk. She landed on her right hand, right wrist and flank. She is not sure if she hit her abdomen, but doesn't think so. She was seen in ER and diagnosed with Boxer's fracture of [MASKED] metacarpal. Her hand was splinted and she was transferred to L and D for further evaluation. She denies ctx, LOF, VB, abdominal pain. +FM. Past Medical History: PMH: ADHD PSH: Wisdom teeth removal Social History: [MASKED] Family History: Non-contributory. Physical Exam: On admission: VSS Constitutional: Gravid well developed, well nourished female, appearing in no acute distress Abdomen: no tenderness and no masses Fundus: size equals dates, nontender and not irritable EFW:Average Sterile speculum exam: Dilation: Closed Effacement: Long Extremity: Hand wrapped per ortho Pertinent Results: [MASKED] 01:04PM FETAL HGB-0 [MASKED] 01:02PM WBC-10.1* RBC-3.67* HGB-12.0 HCT-35.3 MCV-96 MCH-32.7* MCHC-34.0 RDW-13.1 RDWSD-46.1 [MASKED] 01:02PM PLT COUNT-191 [MASKED] 01:02PM [MASKED] PTT-27.2 [MASKED] [MASKED] 01:02PM [MASKED] Brief Hospital Course: Ms. [MASKED] was transferred from the ED to Labor and Delivery. Given significant fall and ongoing contractions, decision made to monitor x 24 hours on L&D. This was uneventful. At the end of this period, she was discharged home with close OB and ortho follow-up. Medications on Admission: PNV Discharge Medications: PNV Discharge Disposition: Home Discharge Diagnosis: Right hand fracture Pregnancy at 33 weeks Discharge Condition: Stable Discharge Instructions: Please keep appointments with Dr. [MASKED] orthopedics as scheduled. Followup Instructions: [MASKED]
[]
[]
[ "O9A213: Injury, poisoning and certain other consequences of external causes complicating pregnancy, third trimester", "S62336A: Displaced fracture of neck of fifth metacarpal bone, right hand, initial encounter for closed fracture", "O4443: Low lying placenta NOS or without hemorrhage, third trimester", "O99343: Other mental disorders complicating pregnancy, third trimester", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z3A33: 33 weeks gestation of pregnancy", "W1839XA: Other fall on same level, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause" ]
10,053,810
26,647,692
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: dapagliflozin Attending: ___. Chief Complaint: Abnormal head CT, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year old active woman with diabetes type 2, hypertension, atrial fibrillation on eliquis, mild cognitive decline (presumed), who presents as hospital-to-hospital transfer for evaluation of abnormal finding on head CT. History obtained by patient and patient's daughter and niece at bedside. Per patient (who digresses quite a bit on conversation), she was feeling well up until about 4 days ago when she became nauseous and started to vomit. She thought she had a stomach bug because she just was not feeling well at all and didn't even good enough to get up out of bed to dust the TV. The patient cannot say if her symptoms suddenly came on. She does endorse some double vision when she does not wear her glasses that "comes and goes" and "gets better" after she puts her glasses on. Additional details regarding nausea and vomiting limited as patient continues to digress in conversations. Her daughter notes that she last saw her mother 5 days ago for ___. She had picked her mother up to celebrate Thanksgiving with the family down at the ___. During that week, while she was watching her mother throughout the day she noticed that her mother's word-finding difficulty was worse and that her appetite was significantly decreased. She also noted that her mother's gait was worse, wobbling to both the left and the right despite use of a cane. The daughter does note that this decline has been ongoing for the past several months, however despite this decline the patient is completely independent at home and continues to work 15 hrs a week at Stop and Shop and continues to drive at night. When asked to elaborate on the decline over the last few months, the daughter notes a slow decline in the patient's word-finding difficulty, disorientation to day and month sometimes. She also notes a ___ weight loss over the past ___ months. ROS challenging as patient continues to digress without clarity of specific details regarding timing/intensity of symptoms noted. She does endorse transient double vision that resolves with wearing glasses, nausea that has subsided, and denies vertigo. She had a frontal throbbing headache but that has since resolved. She thinks her gait is steady with her cane. Her daughter notes that several weeks ago the patient broke out in a rash in her thighs that resolved with a 14d course of doxycycline. Regarding cancer history/risk factors, the patient is a former smoker but quit ___ years ago. She has never carried a diagnosis of cancer. At OSH, she was noted to be hypochloremic (97) and hypomagnesemic (1.4), which was corrected with electrolyte repletion. Past Medical History: diverticulitis s/p surgery diabetes atrial fibrillation hypertension hyperlipidemia bilateral cataract repair bilateral hip repair ___ years ago) Social History: ___ Family History: Sister with skin cancer and then glioblastoma diagnosed at the age of ___ Brother with throat cancer and then died of brain tumor ___ years later Physical Exam: Vitals: T97.6, HR80-110, BP119/70, RR17, 98RA glucose 222 General: Awake, cooperative, appears younger than stated age HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: irregular rate, warm and well-perfused Abdomen: Soft, non-distended. Extremities: trace bipedal edema Skin: inner thighs with maculopapular rash that appears to be resolving (confirmed with daughter that looks better than in prior days) Neurologic: -Mental Status: Alert, oriented to name, location (hospital in ___ but not ___, ___ but not date. Able to relate general history but with significant digressions in story, taking time to describe how she felt too tired to dust the TV then noting that it didn't matter because "they are coming to see her and not the TV" and then telling me how kind they are to visit her and proceeding to elaborate on her family support network. ___ forward is rapid. ___ backwards is slower and the patient only reaches ___ and then digresses. She is able to follow two-step commands. Has ocassional paraphasic errors, referring to "novels" regarding the book she likes to read as "novelities." Repetition intact. Normal prosody. Able to name both high frequency objects but some errors with low-frequency objects. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: post cataract surgery bilateral, PERRL 2>1 and sluggish, EOMI no nystagmus, no ptosis, face appears symmetric hearing diminished to conversation tongue deviates to right, uvula deviates to right right pupil, dysmetria on left finger. -Motor: Decreased bulk, normal tone. No pronator drift. No adventitious movements, such as tremor or asterixis noted. **Full confrontational strength testing limited largely by best effort but to best of ability, patient gives symmetric resistance throughout. [___] L 5 5 5 5 5 5 4 4 4 4 5 5 R 5 5 5 5 5 5 4 4 4 4 5 5 -Sensory: Diminished sensation to pinprick in stocking-glove pattern. Light touch, temperature, vibratory sense intact. -Reflexes: Plantar response was flexor bilaterally. -Coordination: Dysmetria on left FNF, left HKS. Diminished amplitude with fast movements on left hand. -Gait: Deferred secondary to fatigue (patient refused) and absence of cane at bedside. No leaning to one side with sitting on bed with eyes closed. ==================================== DISCHARGE Vitals: Tm/c: 99.1 BP: 107/49 HR: 60 RR: 22 SaO2: 99 General: Awake, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused. Extremities: Symmetric, no edema. Neurologic: -Mental Status: Awake, alert, and oriented to person and time, but thinks she is at a hospital in ___. Attentive, able to name ___ forward and backward without difficulty. Language is fluent with intact comprehension and slightly impaired repetition ("no ifs ands and buts"). There were no paraphasic errors. Naming intact to high and low frequency objects. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing impaired bilaterally to conversation. Palate elevates symmetrically. Tongue protrudes in midline. No dysarthria. -Motor: Decreased bulk. No adventitious movements, such as tremor, noted. Remainder of exam deferred. -Sensory: Deferred. -DTRs: ___. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Patient able to walk evenly with assistance on either side. No wide-based gait or unsteadiness inconsistent with muscle bulk noted. Pertinent Results: ___ 07:29PM BLOOD WBC-4.6 RBC-3.71* Hgb-12.6 Hct-37.0 MCV-100* MCH-34.0* MCHC-34.1 RDW-13.6 RDWSD-49.5* Plt ___ ___ 05:08AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.8 Hct-35.9 MCV-104* MCH-34.0* MCHC-32.9 RDW-14.4 RDWSD-54.4* Plt ___ ___ 07:29PM BLOOD ___ PTT-27.5 ___ ___ 12:40PM BLOOD ___ PTT-26.5 ___ ___ 05:08AM BLOOD ___ PTT-27.1 ___ ___ 07:29PM BLOOD Glucose-230* UreaN-20 Creat-0.7 Na-133* K-4.1 Cl-99 HCO3-22 AnGap-12 ___ 12:40PM BLOOD Glucose-240* UreaN-21* Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-26 AnGap-10 ___ 06:40AM BLOOD Glucose-299* UreaN-30* Creat-0.7 Na-137 K-4.9 Cl-103 HCO3-25 AnGap-9* ___ 05:08AM BLOOD Glucose-257* UreaN-34* Creat-1.0 Na-139 K-4.9 Cl-104 HCO3-28 AnGap-7* ___ 12:40PM BLOOD ALT-8 AST-11 LD(LDH)-160 CK(CPK)-15* AlkPhos-67 TotBili-0.6 ___ 12:40PM BLOOD GGT-15 ___ 07:29PM BLOOD Lipase-20 ___ 07:29PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:40PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 07:29PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.9 Mg-1.7 ___ 12:40PM BLOOD Albumin-3.3* Cholest-102 ___ 05:08AM BLOOD Phos-2.6* Mg-1.6 ___ 12:40PM BLOOD %HbA1c-9.4* eAG-223* ___ 12:40PM BLOOD Triglyc-79 HDL-53 CHOL/HD-1.9 LDLcalc-33 ___ 07:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:40PM BLOOD Lactate-1.5 CTA HEAD ___ FINDINGS: CT HEAD WITHOUT CONTRAST: A 3 x 3.7 cm intra-axial hypodense focus is seen in the left cerebellar hemisphere exerting mass effect on the adjacent fourth ventricle without evidence of associated hydrocephalus. Subtle hyperdensity within the left cerebellar hemisphere lesion suggests possible underlying microhemorrhage. The ventricles and sulci are prominent, consistent global cerebral volume loss. Patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease. The left mastoid air cells are underpneumatized with a small effusion. The visualized portion of the paranasal sinuses,right mastoid air cells,andbilateral middle ear cavities are clear. The visualized portion of the orbits demonstrates sequela of prior bilateral cataract surgery. CTA HEAD: Infundibular origin of the right posterior cerebral artery. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries, by NASCET criteria. Mild atherosclerotic disease narrows the origin of the left common carotid and vertebral arteries. The vertebral arteries appear otherwise unremarkable with no evidence of stenosis or occlusion. The bilateral subclavian arteries are unremarkable allowing for mild atherosclerotic disease. OTHER: The visualized portion of the lungs demonstrates an 8 mm nodule in the right upper lobe, is seen on the prior chest x-ray. A smaller 2 mm right upper lobe nodule also noted. A multinodular goiter is seen, with largest nodule measuring approximately 2.0 cm on the left.. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. 3 x 3.7 cm intra-axial hypodense focus in the left cerebellar hemisphere likely represents a late acute to subacute infarct. No large hemorrhage identified. Possible microhemorrhages within the region of infarct. 2. Allowing for atherosclerotic disease, essentially unremarkable CTA of the head and neck. No evidence of occlusion. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. 8 mm nodule in the right upper lobe. A smaller 2 mm right upper lobe nodule also noted. 4. Multinodular goiter. Largest discrete nodule appears to be approximately 2 cm in the left lobe. 5. Small left mastoid effusion. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule measuring 6 to 8 mm, a CT follow-up in 6 to 12 months is recommended in a low-risk patient, optionally followed by a CT in ___ months. In a high-risk patient, a CT follow-up in 6 to 12 months, and a CT in ___ months is recommended. See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Thyroid nodule. Ultrasound follow up recommended. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or ___, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. MRI BRAIN ___ IMPRESSION: 1. 4 x 5 x 2.3 cm left cerebellar hemisphere focus of diffusion and gradient echo susceptibility artifact, felt to be most compatible with late acute infarct in hemorrhagic transformation. Associated linear foci of enhancement, predominantly located within the cerebellar folia is felt to be secondary to luxury perfusion rather than nodular enhancement of underlying mass lesion. 2. Associated edema pattern results in mass effect and mild effacement of the fourth ventricle. No definite evidence of hydrocephalus. The size of the ventricles are unchanged from outside hospital examination of ___. 3. Recommend repeat MRI head with without contrast in approximately 1 month to document stability or resolution of linear enhancement to exclude underlying lesion. 4. Additional findings as described above. TTE ___ CONCLUSION: The left atrial volume index is mildly increased. The right atrium is mildly enlarged. 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. Quantitative 3D volumetric left ventricular ejection fraction is 63 %. There is a mild (peak 10 mmHg) resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is mild to moderate [___] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness, cavity size, and regional/global systolic function. Increased PCWP. Diastolic dysfunction. Mild to moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. MR PERFUSION ___ FINDINGS: Again seen is cerebellar abnormality on T1 postcontrast images, stable since yesterday. ASL Perfusion: There is decreased perfusion in the left inferior cerebellar hemisphere corresponding to the left cerebellar hemisphere infarct identified on brain MRI 1 day prior.. MR Spectroscopy: Relatively preserved spectroscopy pattern, no evidence of tumor spectra. IMPRESSION: Findings consistent with left cerebellar infarct. Brief Hospital Course: Ms. ___ is a ___ year old right-handed female with a h/o afib on eliquis, TIIDM, and HTN who presents with ___ days of nausea, unsteady gait, and word finding difficulty and was transferred to ___ from OSH after abnormal findings on NCHCT. #Left intrapernchymal cerebellar lesion The patient complains of nausea and gait disturbance lasting ___ days, and the patient's daughter began to notice word finding difficulty and gait disturbance during this same period. The patient's daughter also reported that the patient has been declining cognitively and lost approximately 15 pounds over the past several months. The patient's family history is notable for two incidences of brain cancer, with one confirmed GBM. The patient's physical exam did not provide any localizing or alarming findings, demonstrating minor ataxia that has improved since admission, and the patient is now able to ambulate with assistance. Initial NCHCT showed a hypodense focus in the left cerebellar hemisphere, and CTA did not show any evidence of an occlusion in the head or neck. MRI w/ and w/o contrast showed a left cerebellar hemisphere lesion with restricted diffusion and gradient echo susceptibility. F/u MR perfusion scanning demonstrated hypoperfusion in that region and did not show any evidence of tumor spectra. This lesion most likely represents a subacute venous infarct with surrounding edema and hemorrhagic transformation given the hypoperfusion on MR spectroscopy and preserved spectroscopy pattern. Mass unlikely, Abscess/infection is unlikely given lack of elevated WBC or fever/constitutional symptoms. Stroke risk factor labs show HbA1c 9.4, LDL 33. -Repeat MRI 2 weeks after discharge to monitor concerning changes in lesion (e.g. continued bleed, change in morphology that could suggest mass) -Hold Eliquis for 2 weeks, continue ASA #Cognitive decline -Patient has inattention, difficulty with recall. Will need more thorough mental status/memory/cognition work-up and rehab after discharge. #Afib: -Eliquis held, aspirin continued. This should be re-started AFTER a repeat MRI brain is done in about 2-weeks if the hemorrhage is stable/improved. Her atenolol was decreased from 50mg to 12.5mg daily due to bradycardia. #Diabetes: -The patient was initially started on steroids (decadron) when this lesion was thought to be a mass. Her sugars prior to even starting the steroids however were also elevated and her A1C was elevated at 9.4. -A ___ diabetes consult was placed as her glucose levels were still elevated on a sliding scale insulin regiment and she was discharged on insulin #Gait unsteadiness: -Due to cerebellar stroke, ___ recommended rehab Transitional Issues: -Follow blood sugars very carefully -Repeat MRI in 2 weeks before starting Eliquis -Follow-up with Neurology -Incidental pulmonary and thyroid nodules found on CT, follow-up with PCP for further ___ imaging ========================== 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 =33 ) - () 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 [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x ] 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 - (x) No - If no, why not (I.e. bleeding risk, etc.) () N/A - bleeding risk due to hemorrhagic conversion of ischemic infarct Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Atenolol 50 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol (colesevelam) 6.25 gram oral BREAKFAST Discharge Medications: 1. Glargine 12 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Atenolol 12.5 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol (___) 6.25 gram oral BREAKFAST 6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do not restart Apixaban until after your doctor says it is okay Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute cerebellar infarct with hemorrhagic conversion 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 ___ because you were having difficulty walking, nausea, and some confusion 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. You went to an outside hospital where a cat scan of your brain was done which showed a worrisome lesion. You then were transferred to ___ in ___ where we ran two more tests including two MRI brain scans. We initially thought that the lesion in your brain could have been a mass but on further testing the finding is more consistent with a stroke. 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: ATRIAL FIBRILLATION DIABETES HYPERLIPIDEMIA HYPERTENSION We are worried that you were not taking your medications because your sugar was also high in your blood, therefore we have started you on INSULIN. Your heart rate was low and your blood pressure was good while you were in the hospital, so we decreased your ATENOLOL from 50mg daily to 12.5mg daily. You worked with physical therapy who recommended rehab to get you better and safe as you had this stroke affecting your balance. In two weeks we would like to repeat a scan to ensure that your stroke is improving. In the meantime, do not re-start the eliquis (apixaban) until the scan is done. Once the repeat brain scan has been completed, your facility should re-start the blood thinner at that time. Thank you for involving us in your care. Sincerely, ___ Neurology Followup Instructions: ___
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Allergies: dapagliflozin Chief Complaint: Abnormal head CT, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [MASKED] is a [MASKED] year old active woman with diabetes type 2, hypertension, atrial fibrillation on eliquis, mild cognitive decline (presumed), who presents as hospital-to-hospital transfer for evaluation of abnormal finding on head CT. History obtained by patient and patient's daughter and niece at bedside. Per patient (who digresses quite a bit on conversation), she was feeling well up until about 4 days ago when she became nauseous and started to vomit. She thought she had a stomach bug because she just was not feeling well at all and didn't even good enough to get up out of bed to dust the TV. The patient cannot say if her symptoms suddenly came on. She does endorse some double vision when she does not wear her glasses that "comes and goes" and "gets better" after she puts her glasses on. Additional details regarding nausea and vomiting limited as patient continues to digress in conversations. Her daughter notes that she last saw her mother 5 days ago for [MASKED]. She had picked her mother up to celebrate Thanksgiving with the family down at the [MASKED]. During that week, while she was watching her mother throughout the day she noticed that her mother's word-finding difficulty was worse and that her appetite was significantly decreased. She also noted that her mother's gait was worse, wobbling to both the left and the right despite use of a cane. The daughter does note that this decline has been ongoing for the past several months, however despite this decline the patient is completely independent at home and continues to work 15 hrs a week at Stop and Shop and continues to drive at night. When asked to elaborate on the decline over the last few months, the daughter notes a slow decline in the patient's word-finding difficulty, disorientation to day and month sometimes. She also notes a [MASKED] weight loss over the past [MASKED] months. ROS challenging as patient continues to digress without clarity of specific details regarding timing/intensity of symptoms noted. She does endorse transient double vision that resolves with wearing glasses, nausea that has subsided, and denies vertigo. She had a frontal throbbing headache but that has since resolved. She thinks her gait is steady with her cane. Her daughter notes that several weeks ago the patient broke out in a rash in her thighs that resolved with a 14d course of doxycycline. Regarding cancer history/risk factors, the patient is a former smoker but quit [MASKED] years ago. She has never carried a diagnosis of cancer. At OSH, she was noted to be hypochloremic (97) and hypomagnesemic (1.4), which was corrected with electrolyte repletion. Past Medical History: diverticulitis s/p surgery diabetes atrial fibrillation hypertension hyperlipidemia bilateral cataract repair bilateral hip repair [MASKED] years ago) Social History: [MASKED] Family History: Sister with skin cancer and then glioblastoma diagnosed at the age of [MASKED] Brother with throat cancer and then died of brain tumor [MASKED] years later Physical Exam: Vitals: T97.6, HR80-110, BP119/70, RR17, 98RA glucose 222 General: Awake, cooperative, appears younger than stated age HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: irregular rate, warm and well-perfused Abdomen: Soft, non-distended. Extremities: trace bipedal edema Skin: inner thighs with maculopapular rash that appears to be resolving (confirmed with daughter that looks better than in prior days) Neurologic: -Mental Status: Alert, oriented to name, location (hospital in [MASKED] but not [MASKED], [MASKED] but not date. Able to relate general history but with significant digressions in story, taking time to describe how she felt too tired to dust the TV then noting that it didn't matter because "they are coming to see her and not the TV" and then telling me how kind they are to visit her and proceeding to elaborate on her family support network. [MASKED] forward is rapid. [MASKED] backwards is slower and the patient only reaches [MASKED] and then digresses. She is able to follow two-step commands. Has ocassional paraphasic errors, referring to "novels" regarding the book she likes to read as "novelities." Repetition intact. Normal prosody. Able to name both high frequency objects but some errors with low-frequency objects. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: post cataract surgery bilateral, PERRL 2>1 and sluggish, EOMI no nystagmus, no ptosis, face appears symmetric hearing diminished to conversation tongue deviates to right, uvula deviates to right right pupil, dysmetria on left finger. -Motor: Decreased bulk, normal tone. No pronator drift. No adventitious movements, such as tremor or asterixis noted. **Full confrontational strength testing limited largely by best effort but to best of ability, patient gives symmetric resistance throughout. [[MASKED]] L 5 5 5 5 5 5 4 4 4 4 5 5 R 5 5 5 5 5 5 4 4 4 4 5 5 -Sensory: Diminished sensation to pinprick in stocking-glove pattern. Light touch, temperature, vibratory sense intact. -Reflexes: Plantar response was flexor bilaterally. -Coordination: Dysmetria on left FNF, left HKS. Diminished amplitude with fast movements on left hand. -Gait: Deferred secondary to fatigue (patient refused) and absence of cane at bedside. No leaning to one side with sitting on bed with eyes closed. ==================================== DISCHARGE Vitals: Tm/c: 99.1 BP: 107/49 HR: 60 RR: 22 SaO2: 99 General: Awake, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused. Extremities: Symmetric, no edema. Neurologic: -Mental Status: Awake, alert, and oriented to person and time, but thinks she is at a hospital in [MASKED]. Attentive, able to name [MASKED] forward and backward without difficulty. Language is fluent with intact comprehension and slightly impaired repetition ("no ifs ands and buts"). There were no paraphasic errors. Naming intact to high and low frequency objects. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing impaired bilaterally to conversation. Palate elevates symmetrically. Tongue protrudes in midline. No dysarthria. -Motor: Decreased bulk. No adventitious movements, such as tremor, noted. Remainder of exam deferred. -Sensory: Deferred. -DTRs: [MASKED]. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Patient able to walk evenly with assistance on either side. No wide-based gait or unsteadiness inconsistent with muscle bulk noted. Pertinent Results: [MASKED] 07:29PM BLOOD WBC-4.6 RBC-3.71* Hgb-12.6 Hct-37.0 MCV-100* MCH-34.0* MCHC-34.1 RDW-13.6 RDWSD-49.5* Plt [MASKED] [MASKED] 05:08AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.8 Hct-35.9 MCV-104* MCH-34.0* MCHC-32.9 RDW-14.4 RDWSD-54.4* Plt [MASKED] [MASKED] 07:29PM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 12:40PM BLOOD [MASKED] PTT-26.5 [MASKED] [MASKED] 05:08AM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 07:29PM BLOOD Glucose-230* UreaN-20 Creat-0.7 Na-133* K-4.1 Cl-99 HCO3-22 AnGap-12 [MASKED] 12:40PM BLOOD Glucose-240* UreaN-21* Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-26 AnGap-10 [MASKED] 06:40AM BLOOD Glucose-299* UreaN-30* Creat-0.7 Na-137 K-4.9 Cl-103 HCO3-25 AnGap-9* [MASKED] 05:08AM BLOOD Glucose-257* UreaN-34* Creat-1.0 Na-139 K-4.9 Cl-104 HCO3-28 AnGap-7* [MASKED] 12:40PM BLOOD ALT-8 AST-11 LD(LDH)-160 CK(CPK)-15* AlkPhos-67 TotBili-0.6 [MASKED] 12:40PM BLOOD GGT-15 [MASKED] 07:29PM BLOOD Lipase-20 [MASKED] 07:29PM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 12:40PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 07:29PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.9 Mg-1.7 [MASKED] 12:40PM BLOOD Albumin-3.3* Cholest-102 [MASKED] 05:08AM BLOOD Phos-2.6* Mg-1.6 [MASKED] 12:40PM BLOOD %HbA1c-9.4* eAG-223* [MASKED] 12:40PM BLOOD Triglyc-79 HDL-53 CHOL/HD-1.9 LDLcalc-33 [MASKED] 07:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 07:40PM BLOOD Lactate-1.5 CTA HEAD [MASKED] FINDINGS: CT HEAD WITHOUT CONTRAST: A 3 x 3.7 cm intra-axial hypodense focus is seen in the left cerebellar hemisphere exerting mass effect on the adjacent fourth ventricle without evidence of associated hydrocephalus. Subtle hyperdensity within the left cerebellar hemisphere lesion suggests possible underlying microhemorrhage. The ventricles and sulci are prominent, consistent global cerebral volume loss. Patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease. The left mastoid air cells are underpneumatized with a small effusion. The visualized portion of the paranasal sinuses,right mastoid air cells,andbilateral middle ear cavities are clear. The visualized portion of the orbits demonstrates sequela of prior bilateral cataract surgery. CTA HEAD: Infundibular origin of the right posterior cerebral artery. Otherwise, the vessels of the circle of [MASKED] and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries, by NASCET criteria. Mild atherosclerotic disease narrows the origin of the left common carotid and vertebral arteries. The vertebral arteries appear otherwise unremarkable with no evidence of stenosis or occlusion. The bilateral subclavian arteries are unremarkable allowing for mild atherosclerotic disease. OTHER: The visualized portion of the lungs demonstrates an 8 mm nodule in the right upper lobe, is seen on the prior chest x-ray. A smaller 2 mm right upper lobe nodule also noted. A multinodular goiter is seen, with largest nodule measuring approximately 2.0 cm on the left.. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. 3 x 3.7 cm intra-axial hypodense focus in the left cerebellar hemisphere likely represents a late acute to subacute infarct. No large hemorrhage identified. Possible microhemorrhages within the region of infarct. 2. Allowing for atherosclerotic disease, essentially unremarkable CTA of the head and neck. No evidence of occlusion. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. 8 mm nodule in the right upper lobe. A smaller 2 mm right upper lobe nodule also noted. 4. Multinodular goiter. Largest discrete nodule appears to be approximately 2 cm in the left lobe. 5. Small left mastoid effusion. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule measuring 6 to 8 mm, a CT follow-up in 6 to 12 months is recommended in a low-risk patient, optionally followed by a CT in [MASKED] months. In a high-risk patient, a CT follow-up in 6 to 12 months, and a CT in [MASKED] months is recommended. See the [MASKED] [MASKED] Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: [MASKED] Thyroid nodule. Ultrasound follow up recommended. [MASKED] College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age [MASKED] or 1.5 cm in patients age [MASKED] or [MASKED], or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. MRI BRAIN [MASKED] IMPRESSION: 1. 4 x 5 x 2.3 cm left cerebellar hemisphere focus of diffusion and gradient echo susceptibility artifact, felt to be most compatible with late acute infarct in hemorrhagic transformation. Associated linear foci of enhancement, predominantly located within the cerebellar folia is felt to be secondary to luxury perfusion rather than nodular enhancement of underlying mass lesion. 2. Associated edema pattern results in mass effect and mild effacement of the fourth ventricle. No definite evidence of hydrocephalus. The size of the ventricles are unchanged from outside hospital examination of [MASKED]. 3. Recommend repeat MRI head with without contrast in approximately 1 month to document stability or resolution of linear enhancement to exclude underlying lesion. 4. Additional findings as described above. TTE [MASKED] CONCLUSION: The left atrial volume index is mildly increased. The right atrium is mildly enlarged. 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. Quantitative 3D volumetric left ventricular ejection fraction is 63 %. There is a mild (peak 10 mmHg) resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is mild to moderate [[MASKED]] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness, cavity size, and regional/global systolic function. Increased PCWP. Diastolic dysfunction. Mild to moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. MR PERFUSION [MASKED] FINDINGS: Again seen is cerebellar abnormality on T1 postcontrast images, stable since yesterday. ASL Perfusion: There is decreased perfusion in the left inferior cerebellar hemisphere corresponding to the left cerebellar hemisphere infarct identified on brain MRI 1 day prior.. MR Spectroscopy: Relatively preserved spectroscopy pattern, no evidence of tumor spectra. IMPRESSION: Findings consistent with left cerebellar infarct. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old right-handed female with a h/o afib on eliquis, TIIDM, and HTN who presents with [MASKED] days of nausea, unsteady gait, and word finding difficulty and was transferred to [MASKED] from OSH after abnormal findings on NCHCT. #Left intrapernchymal cerebellar lesion The patient complains of nausea and gait disturbance lasting [MASKED] days, and the patient's daughter began to notice word finding difficulty and gait disturbance during this same period. The patient's daughter also reported that the patient has been declining cognitively and lost approximately 15 pounds over the past several months. The patient's family history is notable for two incidences of brain cancer, with one confirmed GBM. The patient's physical exam did not provide any localizing or alarming findings, demonstrating minor ataxia that has improved since admission, and the patient is now able to ambulate with assistance. Initial NCHCT showed a hypodense focus in the left cerebellar hemisphere, and CTA did not show any evidence of an occlusion in the head or neck. MRI w/ and w/o contrast showed a left cerebellar hemisphere lesion with restricted diffusion and gradient echo susceptibility. F/u MR perfusion scanning demonstrated hypoperfusion in that region and did not show any evidence of tumor spectra. This lesion most likely represents a subacute venous infarct with surrounding edema and hemorrhagic transformation given the hypoperfusion on MR spectroscopy and preserved spectroscopy pattern. Mass unlikely, Abscess/infection is unlikely given lack of elevated WBC or fever/constitutional symptoms. Stroke risk factor labs show HbA1c 9.4, LDL 33. -Repeat MRI 2 weeks after discharge to monitor concerning changes in lesion (e.g. continued bleed, change in morphology that could suggest mass) -Hold Eliquis for 2 weeks, continue ASA #Cognitive decline -Patient has inattention, difficulty with recall. Will need more thorough mental status/memory/cognition work-up and rehab after discharge. #Afib: -Eliquis held, aspirin continued. This should be re-started AFTER a repeat MRI brain is done in about 2-weeks if the hemorrhage is stable/improved. Her atenolol was decreased from 50mg to 12.5mg daily due to bradycardia. #Diabetes: -The patient was initially started on steroids (decadron) when this lesion was thought to be a mass. Her sugars prior to even starting the steroids however were also elevated and her A1C was elevated at 9.4. -A [MASKED] diabetes consult was placed as her glucose levels were still elevated on a sliding scale insulin regiment and she was discharged on insulin #Gait unsteadiness: -Due to cerebellar stroke, [MASKED] recommended rehab Transitional Issues: -Follow blood sugars very carefully -Repeat MRI in 2 weeks before starting Eliquis -Follow-up with Neurology -Incidental pulmonary and thyroid nodules found on CT, follow-up with PCP for further [MASKED] imaging ========================== 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 =33 ) - () 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 [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? () Yes - (x) 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 [x ] 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 - (x) No - If no, why not (I.e. bleeding risk, etc.) () N/A - bleeding risk due to hemorrhagic conversion of ischemic infarct Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Atenolol 50 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol (colesevelam) 6.25 gram oral BREAKFAST Discharge Medications: 1. Glargine 12 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Atenolol 12.5 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol ([MASKED]) 6.25 gram oral BREAKFAST 6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do not restart Apixaban until after your doctor says it is okay Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Acute cerebellar infarct with hemorrhagic conversion 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 [MASKED] because you were having difficulty walking, nausea, and some confusion 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. You went to an outside hospital where a cat scan of your brain was done which showed a worrisome lesion. You then were transferred to [MASKED] in [MASKED] where we ran two more tests including two MRI brain scans. We initially thought that the lesion in your brain could have been a mass but on further testing the finding is more consistent with a stroke. 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: ATRIAL FIBRILLATION DIABETES HYPERLIPIDEMIA HYPERTENSION We are worried that you were not taking your medications because your sugar was also high in your blood, therefore we have started you on INSULIN. Your heart rate was low and your blood pressure was good while you were in the hospital, so we decreased your ATENOLOL from 50mg daily to 12.5mg daily. You worked with physical therapy who recommended rehab to get you better and safe as you had this stroke affecting your balance. In two weeks we would like to repeat a scan to ensure that your stroke is improving. In the meantime, do not re-start the eliquis (apixaban) until the scan is done. Once the repeat brain scan has been completed, your facility should re-start the blood thinner at that time. Thank you for involving us in your care. Sincerely, [MASKED] Neurology Followup Instructions: [MASKED]
[]
[ "I4891", "E119", "Z794", "I10", "E785", "Z66", "E1165", "Z7902", "Y92230" ]
[ "I6389: Other cerebral infarction", "I614: Nontraumatic intracerebral hemorrhage in cerebellum", "R4181: Age-related cognitive decline", "I4891: Unspecified atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "R413: Other amnesia", "R634: Abnormal weight loss", "R4701: Aphasia", "Z66: Do not resuscitate", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R270: Ataxia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R001: Bradycardia, unspecified", "T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R29702: NIHSS score 2" ]
10,053,854
22,192,970
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Asymptomatic with mitral regurgitation and coronary artery disease Major Surgical or Invasive Procedure: ___ Coronary artery bypass graft x 3, Mitral valve repair History of Present Illness: ___ year old male with history of TIA, atrial fibrillation, sleep apnea, hypertension and hyperlipidemia who underwent cardiac evaluation for pre-operative clearance prior to hernia surgery. He admits to mild chest tightness with heavy exertion. He otherwise denies symptoms of frank chest pain, palpitations, dyspnea, fatigue, edema or syncope. Cardiac catheterization revealed severe three vessel coronary artery disease. Presents today to complete pre-op evaluation and for heparin bridge after stopping Xarelto in preparation for surgery tomorrow. Past Medical History: Coronary Artery Disease Mitral Regurgitation Atrial Fibrillation, on Xarelto History of TIA ___ Sleep apnea Hypertension Hyperlipidemia Umbilical Hernia Varicose Veins - right leg s/p Wisdom teeth removal s/p rhinoplasty from nose fracture Social History: ___ Family History: Mother with CAD s/p CABG in her late ___ Physical Exam: BP: 164/72 Pulse: 97 Resp: 16 O2 sat: 99% room air Height: 72 inches Weight: 290 lbs General: resting in bed- slightly anxious regarding surgery. HEENT: Warm [x] Dry [x] intact [x] HEENT: [x] PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally ] Heart: RRR [] Irregular [X] Murmur ] grade ___ systolic murmur best heard along LLSB Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], small umbilical hernia noted Extremities: Warm [x], well-perfused [x]. 12" superficial Scratch noted on left forearm. Edema: None Varicosities: RLE with varicosities and chronic venous stasis changes, LLE without varicosities. Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left: 2 DP Right: palp Left: palp ___ Right: palp Left: palp Radial Right: 2 Left: 2 Carotid Bruit - Right: none Left: none Pertinent Results: Carotid U/S ___: Minimal plaque with bilateral less than 40% carotid stenosis. . Echo ___: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. At least one pulmonary vein may be entering the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. 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 (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post-bypass: The patient is in SR and on a phenylephrine gtt. Biventricular systolic function remains unchanged. Trangastric windows remain poor. Of note there is a small echodensity visible in the left atrial appendage that may represent clot. A mitral ring annuloplasty is seen without significant mitral regurgitation. There is a dynamic component to the exam, notably when the patient is around an SBP of 80 systolic there is mild ___ with resulting eccentric MR. ___ fluid loading and using more phenylephrine the MR disappears and there is no significant ___. The peak and mean gradients across the mitral valve are 5 and 2mmHg respectively. Tricuspid regurgitation remains unchanged. The aorta is intact post decannulation. Admission Labs: ___ WBC-7.1 RBC-5.03 Hgb-15.1 Hct-41.9 MCV-83 MCH-30.0 MCHC-36.0 RDW-12.3 RDWSD-37.3 Plt ___ ___ Neuts-82.5* Lymphs-15.1* Monos-1.5* Eos-0.2* Baso-0.1 Im ___ AbsNeut-7.33* AbsLymp-1.34 AbsMono-0.13* AbsEos-0.02* AbsBaso-0.01 ___ ___ PTT-30.5 ___ ___ Glucose-95 UreaN-21* Creat-1.0 Na-140 K-4.9 Cl-101 HCO3-27 ___ ALT-29 AST-28 AlkPhos-70 Amylase-82 TotBili-1.3 ___ Lipase-56 ___ Mg-2.1 ___ %HbA1c-6.2* eAG-131* Micro: MRSA SCREEN (Final ___: No MRSA isolated. . Chest Film: ___ Unchanged retrocardiac atelectasis, potentially combines to a minimal left pleural effusion. The pre-existing atelectasis at the right lung bases has substantially improved. Moderate cardiomegaly persists. No pulmonary edema. The alignment of the sternal wires is stable. The right venous introduction sheet was removed. . ___ 06:15AM BLOOD WBC-11.6* RBC-3.85* Hgb-11.6* Hct-34.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-12.6 RDWSD-40.7 Plt ___ ___ 08:15AM BLOOD WBC-11.4* RBC-3.76* Hgb-11.4* Hct-34.0* MCV-90 MCH-30.3 MCHC-33.5 RDW-12.7 RDWSD-41.9 Plt ___ ___ 09:30AM BLOOD ___ PTT-26.1 ___ ___ 06:15AM BLOOD ___ PTT-27.3 ___ ___ 10:30AM BLOOD ___ PTT-28.5 ___ ___ 03:30PM BLOOD ___ PTT-29.2 ___ ___ 02:19PM BLOOD ___ PTT-28.5 ___ ___ 05:10PM BLOOD ___ PTT-30.5 ___ ___ 07:10AM BLOOD Glucose-113* UreaN-27* Creat-0.9 Na-137 K-4.3 Cl-99 HCO3-29 AnGap-13 ___ 06:15AM BLOOD Glucose-113* UreaN-24* Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-28 AnGap-11 ___ 07:10AM BLOOD Mg-2.1 Brief Hospital Course: Mr. ___ was admitted the day before surgery for Heparin bridge prior to planned cardiac surgery. On ___ he was brought to the operating room where he underwent a 1. Coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. 2. Mitral valve repair with a 30 ___ annuloplasty band. Cardiopulmonary bypass time was 104 minutes, Cross-clamp time 86 minutes. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. He was weaned from inotropic and vasopressor support. Low dose Beta blocker was initiated. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Rhythm was rate controlled AFib. Anticoagulation was started with Warfarin (on Xarelto pre-op). Gentle diuresis continued. He was seen by physical therapy for strength and motility. He continued to make steady progress and was discharged to home with ___ on POD 4. Dr. ___ will manage ___. Medications on Admission: ATORVASTATIN 40 mg daily hydrochlorothiazide 12.5 mg BID Losartan 50 mg daily Xarelto 20 mg daily- stopped 5 days ago ASA 81 mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Metoprolol Tartrate 12.5 mg PO TID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 6. Furosemide 40 mg PO DAILY Duration: 10 Days RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 7. Warfarin 2 mg PO DAILY16 dose to change daily per Dr. ___ goal INR ___, dx: Afib RX *warfarin 2 mg ___ tablet(s) by mouth daily as directed Disp #*60 Tablet Refills:*1 8. Hydrochlorothiazide 12.5 mg PO BID resume after 10 day course of Furosemide 9. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 10. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x ___ Mitral regurgitation s/p Mitral valve repair Past medical history: Atrial Fibrillation, on Xarelto History of TIA ___ Sleep apnea Hypertension Hyperlipidemia Umbilical Hernia Varicose Veins - right leg Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oxycodone Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage staples to be discontinued at wound check ___ Edema- 1+ Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I2510", "I481", "I429", "I5022", "Z8673", "Z7901", "I10", "E785", "G4730", "Z87891", "Z8249", "I8391", "E669", "Z6837", "D649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Asymptomatic with mitral regurgitation and coronary artery disease Major Surgical or Invasive Procedure: [MASKED] Coronary artery bypass graft x 3, Mitral valve repair History of Present Illness: [MASKED] year old male with history of TIA, atrial fibrillation, sleep apnea, hypertension and hyperlipidemia who underwent cardiac evaluation for pre-operative clearance prior to hernia surgery. He admits to mild chest tightness with heavy exertion. He otherwise denies symptoms of frank chest pain, palpitations, dyspnea, fatigue, edema or syncope. Cardiac catheterization revealed severe three vessel coronary artery disease. Presents today to complete pre-op evaluation and for heparin bridge after stopping Xarelto in preparation for surgery tomorrow. Past Medical History: Coronary Artery Disease Mitral Regurgitation Atrial Fibrillation, on Xarelto History of TIA [MASKED] Sleep apnea Hypertension Hyperlipidemia Umbilical Hernia Varicose Veins - right leg s/p Wisdom teeth removal s/p rhinoplasty from nose fracture Social History: [MASKED] Family History: Mother with CAD s/p CABG in her late [MASKED] Physical Exam: BP: 164/72 Pulse: 97 Resp: 16 O2 sat: 99% room air Height: 72 inches Weight: 290 lbs General: resting in bed- slightly anxious regarding surgery. HEENT: Warm [x] Dry [x] intact [x] HEENT: [x] PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally ] Heart: RRR [] Irregular [X] Murmur ] grade [MASKED] systolic murmur best heard along LLSB Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], small umbilical hernia noted Extremities: Warm [x], well-perfused [x]. 12" superficial Scratch noted on left forearm. Edema: None Varicosities: RLE with varicosities and chronic venous stasis changes, LLE without varicosities. Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left: 2 DP Right: palp Left: palp [MASKED] Right: palp Left: palp Radial Right: 2 Left: 2 Carotid Bruit - Right: none Left: none Pertinent Results: Carotid U/S [MASKED]: Minimal plaque with bilateral less than 40% carotid stenosis. . Echo [MASKED]: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. At least one pulmonary vein may be entering the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. 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 (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post-bypass: The patient is in SR and on a phenylephrine gtt. Biventricular systolic function remains unchanged. Trangastric windows remain poor. Of note there is a small echodensity visible in the left atrial appendage that may represent clot. A mitral ring annuloplasty is seen without significant mitral regurgitation. There is a dynamic component to the exam, notably when the patient is around an SBP of 80 systolic there is mild [MASKED] with resulting eccentric MR. [MASKED] fluid loading and using more phenylephrine the MR disappears and there is no significant [MASKED]. The peak and mean gradients across the mitral valve are 5 and 2mmHg respectively. Tricuspid regurgitation remains unchanged. The aorta is intact post decannulation. Admission Labs: [MASKED] WBC-7.1 RBC-5.03 Hgb-15.1 Hct-41.9 MCV-83 MCH-30.0 MCHC-36.0 RDW-12.3 RDWSD-37.3 Plt [MASKED] [MASKED] Neuts-82.5* Lymphs-15.1* Monos-1.5* Eos-0.2* Baso-0.1 Im [MASKED] AbsNeut-7.33* AbsLymp-1.34 AbsMono-0.13* AbsEos-0.02* AbsBaso-0.01 [MASKED] [MASKED] PTT-30.5 [MASKED] [MASKED] Glucose-95 UreaN-21* Creat-1.0 Na-140 K-4.9 Cl-101 HCO3-27 [MASKED] ALT-29 AST-28 AlkPhos-70 Amylase-82 TotBili-1.3 [MASKED] Lipase-56 [MASKED] Mg-2.1 [MASKED] %HbA1c-6.2* eAG-131* Micro: MRSA SCREEN (Final [MASKED]: No MRSA isolated. . Chest Film: [MASKED] Unchanged retrocardiac atelectasis, potentially combines to a minimal left pleural effusion. The pre-existing atelectasis at the right lung bases has substantially improved. Moderate cardiomegaly persists. No pulmonary edema. The alignment of the sternal wires is stable. The right venous introduction sheet was removed. . [MASKED] 06:15AM BLOOD WBC-11.6* RBC-3.85* Hgb-11.6* Hct-34.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-12.6 RDWSD-40.7 Plt [MASKED] [MASKED] 08:15AM BLOOD WBC-11.4* RBC-3.76* Hgb-11.4* Hct-34.0* MCV-90 MCH-30.3 MCHC-33.5 RDW-12.7 RDWSD-41.9 Plt [MASKED] [MASKED] 09:30AM BLOOD [MASKED] PTT-26.1 [MASKED] [MASKED] 06:15AM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 10:30AM BLOOD [MASKED] PTT-28.5 [MASKED] [MASKED] 03:30PM BLOOD [MASKED] PTT-29.2 [MASKED] [MASKED] 02:19PM BLOOD [MASKED] PTT-28.5 [MASKED] [MASKED] 05:10PM BLOOD [MASKED] PTT-30.5 [MASKED] [MASKED] 07:10AM BLOOD Glucose-113* UreaN-27* Creat-0.9 Na-137 K-4.3 Cl-99 HCO3-29 AnGap-13 [MASKED] 06:15AM BLOOD Glucose-113* UreaN-24* Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-28 AnGap-11 [MASKED] 07:10AM BLOOD Mg-2.1 Brief Hospital Course: Mr. [MASKED] was admitted the day before surgery for Heparin bridge prior to planned cardiac surgery. On [MASKED] he was brought to the operating room where he underwent a 1. Coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. 2. Mitral valve repair with a 30 [MASKED] annuloplasty band. Cardiopulmonary bypass time was 104 minutes, Cross-clamp time 86 minutes. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. He was weaned from inotropic and vasopressor support. Low dose Beta blocker was initiated. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Rhythm was rate controlled AFib. Anticoagulation was started with Warfarin (on Xarelto pre-op). Gentle diuresis continued. He was seen by physical therapy for strength and motility. He continued to make steady progress and was discharged to home with [MASKED] on POD 4. Dr. [MASKED] will manage [MASKED]. Medications on Admission: ATORVASTATIN 40 mg daily hydrochlorothiazide 12.5 mg BID Losartan 50 mg daily Xarelto 20 mg daily- stopped 5 days ago ASA 81 mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Metoprolol Tartrate 12.5 mg PO TID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 5. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 6. Furosemide 40 mg PO DAILY Duration: 10 Days RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 7. Warfarin 2 mg PO DAILY16 dose to change daily per Dr. [MASKED] goal INR [MASKED], dx: Afib RX *warfarin 2 mg [MASKED] tablet(s) by mouth daily as directed Disp #*60 Tablet Refills:*1 8. Hydrochlorothiazide 12.5 mg PO BID resume after 10 day course of Furosemide 9. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 10. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x [MASKED] Mitral regurgitation s/p Mitral valve repair Past medical history: Atrial Fibrillation, on Xarelto History of TIA [MASKED] Sleep apnea Hypertension Hyperlipidemia Umbilical Hernia Varicose Veins - right leg Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oxycodone Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage staples to be discontinued at wound check [MASKED] Edema- 1+ Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "I2510", "Z8673", "Z7901", "I10", "E785", "Z87891", "E669", "D649" ]
[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I481: Persistent atrial fibrillation", "I429: Cardiomyopathy, unspecified", "I5022: Chronic systolic (congestive) heart failure", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G4730: Sleep apnea, unspecified", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "I8391: Asymptomatic varicose veins of right lower extremity", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "D649: Anemia, unspecified" ]
10,054,237
27,785,875
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Neck pain Major Surgical or Invasive Procedure: ___ C6-7 ACDF History of Present Illness: ___ presenting with neck pain with MRI showing C6C7 disc herniation w/o cord compression or myelopathy Past Medical History: Chronic back pain s/p L4L5 laminectomy+discectomy in ___ Social History: ___ Family History: Mother with back problems and surgeries Physical Exam: Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious Orientation: [X]Person [X]Place [X]Time Follows commands: [ ]Simple [X]Complex [ ]None Pupils: Right ___ Left ___ EOM: [X]Full [ ]Restricted Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No Pronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No Comprehension intact [X]Yes [ ]No Motor: ___ throughout Wound: Dressing c/d/i, collar in place Pertinent Results: Please see OMR Brief Hospital Course: Ms. ___ is a ___ with C6C7 disc herniation, who underwent an uncomplicated C6-7 ACDF on ___ by Dr. ___. The postoperative course was uncomplicated and is summarized by systems below: Neuro: A X-ray of the C-spine was performed on POD#0 and showed no C6-7 ACDF without acute complications. Pain was well controlled on an oral regimen. A hard collar was given. She was continued on her home wellbutrin, Lexapro, and Adderall. GI: Diet was advanced as tolerated. She had no problems on a bedside swallow exam performed on POD#1. GU: She voided postoperatively without complications. ID: Perioperative Ancef was given. Heme: SCDs were given for DVT prophylaxis. By the time of discharge on POD#1, she was tolerating a regular diet, voiding, ambulating, and with adequate pain control. Medications on Admission: Bupropion ER 150, Adderall 45, Lexapro 20, medical marijuana Discharge Medications: Bupropion ER 150, Adderall 45, Lexapro 20, oxycodone, Tylenol Discharge Disposition: Home Discharge Diagnosis: C6-7 disc herniation Discharge Condition: Stable Discharge Instructions: Surgery •Your dressing may come off on the second day after surgery. •Please keep wearing the hard collar until your follow-up appointment. •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 •You must wear your cervical collar at all times. The collar helps with healing and alignment of the fusion. •You must wear your cervical collar while showering. •You may remove your collar briefly for skin care (be sure not to twist or bend your neck too much while the collar is off). It is important to look at your skin and be sure there are no wounds of the skin forming. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. 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: ___
[ "M50223", "F17210", "M545" ]
Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: Neck pain Major Surgical or Invasive Procedure: [MASKED] C6-7 ACDF History of Present Illness: [MASKED] presenting with neck pain with MRI showing C6C7 disc herniation w/o cord compression or myelopathy Past Medical History: Chronic back pain s/p L4L5 laminectomy+discectomy in [MASKED] Social History: [MASKED] Family History: Mother with back problems and surgeries Physical Exam: Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious Orientation: [X]Person [X]Place [X]Time Follows commands: [ ]Simple [X]Complex [ ]None Pupils: Right [MASKED] Left [MASKED] EOM: [X]Full [ ]Restricted Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No Pronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No Comprehension intact [X]Yes [ ]No Motor: [MASKED] throughout Wound: Dressing c/d/i, collar in place Pertinent Results: Please see OMR Brief Hospital Course: Ms. [MASKED] is a [MASKED] with C6C7 disc herniation, who underwent an uncomplicated C6-7 ACDF on [MASKED] by Dr. [MASKED]. The postoperative course was uncomplicated and is summarized by systems below: Neuro: A X-ray of the C-spine was performed on POD#0 and showed no C6-7 ACDF without acute complications. Pain was well controlled on an oral regimen. A hard collar was given. She was continued on her home wellbutrin, Lexapro, and Adderall. GI: Diet was advanced as tolerated. She had no problems on a bedside swallow exam performed on POD#1. GU: She voided postoperatively without complications. ID: Perioperative Ancef was given. Heme: SCDs were given for DVT prophylaxis. By the time of discharge on POD#1, she was tolerating a regular diet, voiding, ambulating, and with adequate pain control. Medications on Admission: Bupropion ER 150, Adderall 45, Lexapro 20, medical marijuana Discharge Medications: Bupropion ER 150, Adderall 45, Lexapro 20, oxycodone, Tylenol Discharge Disposition: Home Discharge Diagnosis: C6-7 disc herniation Discharge Condition: Stable Discharge Instructions: Surgery •Your dressing may come off on the second day after surgery. •Please keep wearing the hard collar until your follow-up appointment. •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 •You must wear your cervical collar at all times. The collar helps with healing and alignment of the fusion. •You must wear your cervical collar while showering. •You may remove your collar briefly for skin care (be sure not to twist or bend your neck too much while the collar is off). It is important to look at your skin and be sure there are no wounds of the skin forming. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. 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]
[]
[ "F17210" ]
[ "M50223: Other cervical disc displacement at C6-C7 level", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M545: Low back pain" ]
10,054,496
25,245,648
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 feel like people hate me." Major Surgical or Invasive Procedure: None History of Present Illness: Emergency department psychiatric consultation: Mr. ___ ___ is a ___ year old man, student at ___ with a history of schizoaffective disorder who was brought in after campus security was alerted by a friend of the patient that he had been experiencing worsening paranoid ideation, auditory hallucination, and suicidal ideation. On interview, the patient reported that he had been having worsening auditory hallucinations with derogatory content; voices calling him 'sick', 'disgusting', 'a loser' and 'crazy'. The patient expressed that he felt like 'everyone is talking about me... except my sisters and parents' and people are 'giving me looks', and 'I'm starting to get agitated and annoying and starting to question everyone.' When asked how he had come to the hospital, he explained that he was brought here by campus security. When asked why they would be concerned enough to bring him to the hospital, the patient ultimately explained that he had confided in a friend (___) that he had been experiencing worsening AH, SI and paranoid ideation. He felt like people were trying to control him, and he explained that although he had no active plan and had not researched or rehearsed any modes of suicide, he was feeling more concerned that he might act on his thoughts. When asked more specifically if he had any tentative plans, he explained that he had only really considered jumping in front of a car. When asked about previous attempts, he explained that in high school, he had tried to hang himself and in ___ or ___, he had attempted to overdose on his medications. Additionally in ___, he had attempted to cut his wrist with the intent to kill himself; however, he explained that the cut was superficial and that he had not required medical care. The patient noted that over the past week, he had missed as many as three days of his medications, which he attributed to forgetfulness. However, he denied recent drug use outside of 'a few sips' of alcohol on ___. Otherwise, the patient expressed that overnight in the emergency room, his AH had improved, and he explained that whenever he feels 'vulnerable', his symptoms begin to remit to some degree. However, he did endorse some paranoid ideation stating that he felt like the nurses were talking about him and did not like him. The patient also shared that he has a friend who is a former girlfriend named ___ who also suffers from 'schizophrenia'. He explained that he felt as though his symptoms became worse in the context of being around her. He also went on to describe his relationship with her as 'fake' and as 'a hallucination'; however, he was unable to further characterize what he meant. Collateral: Per conversation with psychiatrist Dr. ___ at ___ ___: Patient carries diagnosis of schizoaffective d/o; he is chronically symptomatic specifically with AH c derogatory content and mania-like symptoms (ie racing thoughts and labile mood). Additionally, although not chronic as with many of his other symptoms, the patient has reportedly endorsed suicidal ideation in the past. The patient has somewhat poor insight and often minimizes his symptoms. His symptoms appear to be somewhat stress responsive and worsen in the context of academic or relationship stress. There is also some concern for substance use with cannabis, cocaine and alcohol as well as some concern regarding possible nonadherence with medications; however, the patient does present consistently to receive his Sustenna ___. Medications are Haloperidol 20 mg PO qHS, Cogentin 2 mg PO qHS, Lithium 300 mg PO qAM and 600 mg PO qHS plus monthly Invega sustenna 234 mg IM. The Lithium was initiated to address the patient's racing thoughts and mood lability. Dr. ___ ___ transition to partial hospitalization program following inpatient hospitalization given the patient's somewhat treatment refractory course and propensity to decompensate without close care given possible nonadherence and substance use. The patient's primary clinician at ___ is Mr. ___ ___. Collateral from ED note: ___ Police ___ ______) reports that a faculty member notified the police that a student had expressed concerns that Mr ___ had made suicidal statements and had made vague references to harming others, he also expressed "he was on speed" and has been awake for a day or two. When he was found by police he was face down and appeared intoxicated. Per telephone conversation with patient's mother Ms. ___ ___ at ___: She explained that she monitors his ___ bank account and spoke to him and that he has been eating very little if at all and has been drinking a lot of coffee and had not slept for the past couple of days. She also noted that he had reported having missed his medications particularly when staying with friends. She noted that the patient has been sad about his ex girlfriend who does not want to speak with him. Additionally, she noted that the patient had a 'bad experience' at ___ where another patient had 'asked him if he could suck his ___ she explained that this patient had been transferred as a result. She also explained that he had felt as though he had a bad experience during his ___ hospitalization; he told her 'he felt like more of an insane person'. She explained that every now and then he just says that he is going to kill himself. She emphatically clarified, 'He will not do it.' She explained that 'people that don't understand him misunderstand him'. She requested that the patient be discharged from the ED tomorrow, so he could go to ___ for his Invega sustenna injection so as to not pay for the entire injection out of pocket if administered elsewhere. Additionally, she noted that she is concerned about payment given that her insurance does not cover mental health and that she is still paying off the patient's hospitalization at ___. Furthermore, she explained that she had been forced to sell her car to help finance the patient's psychiatric care. Past Medical History: Psychiatric history: - Hospitalizations: ___ in ___, another hospitalization at ___ inpatient psychiatry in ___ - Current treaters and treatment: Dr. ___ @ ___, Dr ___ at ___ ___ Recently started with new psychiatrist at ___ (___?) Dr ___ ___ - Medication and ECT trials: risperidone (no benefit); fluphenazine (improved, then switched to haloperidol for lower cost), lithium - Self-injury: in high school, he had tried to hang himself and in ___ or so, he had attempted to overdose on his medications. Additionally in ___, he had attempted to cut his wrist with the intent to kill himself; however, he explained that the cut was superficial and that he had not required medical care. - Harm to others: none - Access to weapons: none - Trauma: 'maid' touched him sexually when he was ___ but says this was not traumatic. Social History: ___ Family History: Mother with prior depression vs. bipolar disorder; sister with depression vs. bipolar disorder Physical Exam: VS: T 98.0F, BP 125/68, HR 81, RR 16, SpO2 100% RA - Neurological: * station and gait: normal/normal * tone and strength: grossly normal, freely moves limbs * cranial nerves: II-XII grossly symmetrical * abnormal movements: none * appearance: age appearing man, spectacled, wearing sweatpants with ___ shorts over them, shirt with paint on it, beanie hat, adequate hygiene and grooming, no apparent distress * behavior: calm, cooperative, pleasant * mood / affect: "fine" with expansive affect * thought process: tangential with some loosening of associations * thought content: no thoughts of self harm; no thoughts of violence; endorses chronic auditory hallucinations, endorses delusional paranoia of people hating him * judgment and Insight: poor judgment as evidenced by his discontinuation of medications and substance abuse; insight fluctuates at times acknowledging his psychosis and later in the interview stating he merely was anxious - Cognition: * attention, *orientation, and executive function: attentive to exam, oriented to self and interviewer, executive function grossly intact * memory: able to recall yesterday's events and HPI * fund of knowledge: no change * speech: pressured, rapid, but interruptible * language: good vocabulary/syntax intact Pertinent Results: ___ 09:20PM GLUCOSE-112* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14 ___ 09:20PM estGFR-Using this ___ 09:20PM CALCIUM-9.3 PHOSPHATE-5.0* MAGNESIUM-2.3 ___ 09:20PM TSH-1.0 ___ 09:20PM WBC-9.7 RBC-5.44 HGB-15.3 HCT-47.7 MCV-88 MCH-28.1 MCHC-32.1 RDW-14.3 RDWSD-45.8 ___ 09:20PM NEUTS-45.7 ___ MONOS-8.5 EOS-9.8* BASOS-1.0 IM ___ AbsNeut-4.43 AbsLymp-3.36 AbsMono-0.83* AbsEos-0.95* AbsBaso-0.10* ___ 09:20PM PLT COUNT-233 ___ 02:13AM LITHIUM-LESS THAN 0.2 ___ 02:13AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: Legal / safety: Mr. ___ signed a conditional voluntary statement on admission, accepted by the overnight intern. He is on standard Q15 minute checks and feels safe on the unit. Sharps status: green Pyschiatric: On admission, he admits to having self-discontinued his medications ___ to wanting to "increase his creative drive and ability to do work" but demonstrates good insight into the fact that he overshot the mark. Reported sleeping very few hours over the last week, becoming more disorganized, more paranoid, with worsening voices and delusions, resulting in low mood and intermittent SI. Also endorses recent drug use, including amphetamines and marijuana. He was initially very pressured, tangential, and with loose associations on exam, endorses magical thinking as well and is difficult to follow at times. He was amenable to restarting his medications in order to get back to his baseline. Specifically, he was restarted on his home haloperidol 20mg QHS, lithium 900mg QHS, benztropine 2mg and he had his ___ 234mg delivered on ___ He had a case conference with his outpatient psychiatrist, Dr. ___ agreed he would be amenable for discharge today. He does have a chronic baseline of pressured speech and somewhat disorganized thought process but functions well in school. He discussed with Mr. ___ the dangers of relapse, especially concerning lack of sleep, substance use, stopping his medications, and sleeplessness. Also invited into the case conference was Mr. ___ sister, ___ also agreed that her brother was ready for discharge and looked much improved since a few days ago when he was very unresponsive to her in conversation. She states he does much better around his family. He agreed that he trusts his sister and is comfortable telling her when he starts to develop patterns of instability. The team discussed the indications for, intended benefits of, and possible side effects and risks of haloperidol and ___ long acting injectable, and risks and benefits of possible alternatives, including not taking the medications, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medications. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself based upon his expression of suicidality. His static factors noted at that time include history of suicide attempts, trauma history, chronic mental illness, history of substance abuse, and male gender. The modifiable risk factors included psychosis, disorganized thought process, medication noncompliance, insomnia, and active substance use disorder. These were addressed by adding back his home medications and holding in a substance free environment. He was able to acknowledge that his substance use, sleeplessness, and medication nonadherence led to his decompensation. Finally, the patient is being discharged with protective risk factors, including future-oriented viewpoint, positive therapeutic relationship with outpatient providers, lack of suicidal ideation during inpatient stay, and strong social supports from family. 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. Haloperidol 20 mg PO QHS 2. Benztropine Mesylate 2 mg PO QHS 3. Lithium Carbonate 300 mg PO QAM 4. Lithium Carbonate 600 mg PO QHS 5. ___ Palmitate 234 mg IM Q1MO (WE) Discharge Medications: 1. Benztropine Mesylate 2 mg PO QHS 2. Haloperidol 20 mg PO QHS 3. Lithium Carbonate 900 mg PO QHS 4. ___ Palmitate 234 mg IM Q1MO (WE) Discharge Disposition: Home Discharge Diagnosis: schizoaffective disorder Discharge Condition: - Data: ___ BMP, CBC w/ differential, serum toxicology, and TSH within normal limits; lithium level less than 0.2 - Exam: * VS: T 98.3F, BP 139/71, HR 90, SpO2 100% RA - Neurological: * station and gait: normal/normal * tone and strength: grossly normal, freely moves limbs * cranial nerves: II-XII grossly symmetrical * abnormal movements: none * appearance: age appearing man, spectacled, wearing sweatpants with ___ shorts over them, shirt with paint on it, beanie hat, adequate hygiene and grooming, no apparent distress * behavior: calm, cooperative, pleasant * mood / affect: 'fine' with expansive affect * thought process: tangential with loosening of associations * thought content: no thoughts of self harm; no thoughts of violence; endorses chronic auditory hallucinations, endorses delusional paranoia of people hating him * judgment and Insight: poor judgment as evidenced by his discontinuation of medications and substance abuse; insight fluctuates at times acknowledging his psychosis and later in the interview stating he merely was anxious - Cognition: * attention, *orientation, and executive function: attentive to exam, oriented to self and interviewer, executive function grossly intact * memory: able to recall yesterday's events and HPI * fund of knowledge: no change * calculations: deferred * abstraction: deferred * visuospatial: deferred * speech: normal rate, prosody, volume * language: good vocabulary/syntax intact Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. *It was a pleasure to have worked with you, and we wish you the best of health.* Followup Instructions: ___
[ "F209", "R45851", "R440", "F17210", "F1210", "F1590" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I feel like people hate me." Major Surgical or Invasive Procedure: None History of Present Illness: Emergency department psychiatric consultation: Mr. [MASKED] [MASKED] is a [MASKED] year old man, student at [MASKED] with a history of schizoaffective disorder who was brought in after campus security was alerted by a friend of the patient that he had been experiencing worsening paranoid ideation, auditory hallucination, and suicidal ideation. On interview, the patient reported that he had been having worsening auditory hallucinations with derogatory content; voices calling him 'sick', 'disgusting', 'a loser' and 'crazy'. The patient expressed that he felt like 'everyone is talking about me... except my sisters and parents' and people are 'giving me looks', and 'I'm starting to get agitated and annoying and starting to question everyone.' When asked how he had come to the hospital, he explained that he was brought here by campus security. When asked why they would be concerned enough to bring him to the hospital, the patient ultimately explained that he had confided in a friend ([MASKED]) that he had been experiencing worsening AH, SI and paranoid ideation. He felt like people were trying to control him, and he explained that although he had no active plan and had not researched or rehearsed any modes of suicide, he was feeling more concerned that he might act on his thoughts. When asked more specifically if he had any tentative plans, he explained that he had only really considered jumping in front of a car. When asked about previous attempts, he explained that in high school, he had tried to hang himself and in [MASKED] or [MASKED], he had attempted to overdose on his medications. Additionally in [MASKED], he had attempted to cut his wrist with the intent to kill himself; however, he explained that the cut was superficial and that he had not required medical care. The patient noted that over the past week, he had missed as many as three days of his medications, which he attributed to forgetfulness. However, he denied recent drug use outside of 'a few sips' of alcohol on [MASKED]. Otherwise, the patient expressed that overnight in the emergency room, his AH had improved, and he explained that whenever he feels 'vulnerable', his symptoms begin to remit to some degree. However, he did endorse some paranoid ideation stating that he felt like the nurses were talking about him and did not like him. The patient also shared that he has a friend who is a former girlfriend named [MASKED] who also suffers from 'schizophrenia'. He explained that he felt as though his symptoms became worse in the context of being around her. He also went on to describe his relationship with her as 'fake' and as 'a hallucination'; however, he was unable to further characterize what he meant. Collateral: Per conversation with psychiatrist Dr. [MASKED] at [MASKED] [MASKED]: Patient carries diagnosis of schizoaffective d/o; he is chronically symptomatic specifically with AH c derogatory content and mania-like symptoms (ie racing thoughts and labile mood). Additionally, although not chronic as with many of his other symptoms, the patient has reportedly endorsed suicidal ideation in the past. The patient has somewhat poor insight and often minimizes his symptoms. His symptoms appear to be somewhat stress responsive and worsen in the context of academic or relationship stress. There is also some concern for substance use with cannabis, cocaine and alcohol as well as some concern regarding possible nonadherence with medications; however, the patient does present consistently to receive his Sustenna [MASKED]. Medications are Haloperidol 20 mg PO qHS, Cogentin 2 mg PO qHS, Lithium 300 mg PO qAM and 600 mg PO qHS plus monthly Invega sustenna 234 mg IM. The Lithium was initiated to address the patient's racing thoughts and mood lability. Dr. [MASKED] [MASKED] transition to partial hospitalization program following inpatient hospitalization given the patient's somewhat treatment refractory course and propensity to decompensate without close care given possible nonadherence and substance use. The patient's primary clinician at [MASKED] is Mr. [MASKED] [MASKED]. Collateral from ED note: [MASKED] Police [MASKED] [MASKED]) reports that a faculty member notified the police that a student had expressed concerns that Mr [MASKED] had made suicidal statements and had made vague references to harming others, he also expressed "he was on speed" and has been awake for a day or two. When he was found by police he was face down and appeared intoxicated. Per telephone conversation with patient's mother Ms. [MASKED] [MASKED] at [MASKED]: She explained that she monitors his [MASKED] bank account and spoke to him and that he has been eating very little if at all and has been drinking a lot of coffee and had not slept for the past couple of days. She also noted that he had reported having missed his medications particularly when staying with friends. She noted that the patient has been sad about his ex girlfriend who does not want to speak with him. Additionally, she noted that the patient had a 'bad experience' at [MASKED] where another patient had 'asked him if he could suck his [MASKED] she explained that this patient had been transferred as a result. She also explained that he had felt as though he had a bad experience during his [MASKED] hospitalization; he told her 'he felt like more of an insane person'. She explained that every now and then he just says that he is going to kill himself. She emphatically clarified, 'He will not do it.' She explained that 'people that don't understand him misunderstand him'. She requested that the patient be discharged from the ED tomorrow, so he could go to [MASKED] for his Invega sustenna injection so as to not pay for the entire injection out of pocket if administered elsewhere. Additionally, she noted that she is concerned about payment given that her insurance does not cover mental health and that she is still paying off the patient's hospitalization at [MASKED]. Furthermore, she explained that she had been forced to sell her car to help finance the patient's psychiatric care. Past Medical History: Psychiatric history: - Hospitalizations: [MASKED] in [MASKED], another hospitalization at [MASKED] inpatient psychiatry in [MASKED] - Current treaters and treatment: Dr. [MASKED] @ [MASKED], Dr [MASKED] at [MASKED] [MASKED] Recently started with new psychiatrist at [MASKED] ([MASKED]?) Dr [MASKED] [MASKED] - Medication and ECT trials: risperidone (no benefit); fluphenazine (improved, then switched to haloperidol for lower cost), lithium - Self-injury: in high school, he had tried to hang himself and in [MASKED] or so, he had attempted to overdose on his medications. Additionally in [MASKED], he had attempted to cut his wrist with the intent to kill himself; however, he explained that the cut was superficial and that he had not required medical care. - Harm to others: none - Access to weapons: none - Trauma: 'maid' touched him sexually when he was [MASKED] but says this was not traumatic. Social History: [MASKED] Family History: Mother with prior depression vs. bipolar disorder; sister with depression vs. bipolar disorder Physical Exam: VS: T 98.0F, BP 125/68, HR 81, RR 16, SpO2 100% RA - Neurological: * station and gait: normal/normal * tone and strength: grossly normal, freely moves limbs * cranial nerves: II-XII grossly symmetrical * abnormal movements: none * appearance: age appearing man, spectacled, wearing sweatpants with [MASKED] shorts over them, shirt with paint on it, beanie hat, adequate hygiene and grooming, no apparent distress * behavior: calm, cooperative, pleasant * mood / affect: "fine" with expansive affect * thought process: tangential with some loosening of associations * thought content: no thoughts of self harm; no thoughts of violence; endorses chronic auditory hallucinations, endorses delusional paranoia of people hating him * judgment and Insight: poor judgment as evidenced by his discontinuation of medications and substance abuse; insight fluctuates at times acknowledging his psychosis and later in the interview stating he merely was anxious - Cognition: * attention, *orientation, and executive function: attentive to exam, oriented to self and interviewer, executive function grossly intact * memory: able to recall yesterday's events and HPI * fund of knowledge: no change * speech: pressured, rapid, but interruptible * language: good vocabulary/syntax intact Pertinent Results: [MASKED] 09:20PM GLUCOSE-112* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14 [MASKED] 09:20PM estGFR-Using this [MASKED] 09:20PM CALCIUM-9.3 PHOSPHATE-5.0* MAGNESIUM-2.3 [MASKED] 09:20PM TSH-1.0 [MASKED] 09:20PM WBC-9.7 RBC-5.44 HGB-15.3 HCT-47.7 MCV-88 MCH-28.1 MCHC-32.1 RDW-14.3 RDWSD-45.8 [MASKED] 09:20PM NEUTS-45.7 [MASKED] MONOS-8.5 EOS-9.8* BASOS-1.0 IM [MASKED] AbsNeut-4.43 AbsLymp-3.36 AbsMono-0.83* AbsEos-0.95* AbsBaso-0.10* [MASKED] 09:20PM PLT COUNT-233 [MASKED] 02:13AM LITHIUM-LESS THAN 0.2 [MASKED] 02:13AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: Legal / safety: Mr. [MASKED] signed a conditional voluntary statement on admission, accepted by the overnight intern. He is on standard Q15 minute checks and feels safe on the unit. Sharps status: green Pyschiatric: On admission, he admits to having self-discontinued his medications [MASKED] to wanting to "increase his creative drive and ability to do work" but demonstrates good insight into the fact that he overshot the mark. Reported sleeping very few hours over the last week, becoming more disorganized, more paranoid, with worsening voices and delusions, resulting in low mood and intermittent SI. Also endorses recent drug use, including amphetamines and marijuana. He was initially very pressured, tangential, and with loose associations on exam, endorses magical thinking as well and is difficult to follow at times. He was amenable to restarting his medications in order to get back to his baseline. Specifically, he was restarted on his home haloperidol 20mg QHS, lithium 900mg QHS, benztropine 2mg and he had his [MASKED] 234mg delivered on [MASKED] He had a case conference with his outpatient psychiatrist, Dr. [MASKED] agreed he would be amenable for discharge today. He does have a chronic baseline of pressured speech and somewhat disorganized thought process but functions well in school. He discussed with Mr. [MASKED] the dangers of relapse, especially concerning lack of sleep, substance use, stopping his medications, and sleeplessness. Also invited into the case conference was Mr. [MASKED] sister, [MASKED] also agreed that her brother was ready for discharge and looked much improved since a few days ago when he was very unresponsive to her in conversation. She states he does much better around his family. He agreed that he trusts his sister and is comfortable telling her when he starts to develop patterns of instability. The team discussed the indications for, intended benefits of, and possible side effects and risks of haloperidol and [MASKED] long acting injectable, and risks and benefits of possible alternatives, including not taking the medications, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medications. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself based upon his expression of suicidality. His static factors noted at that time include history of suicide attempts, trauma history, chronic mental illness, history of substance abuse, and male gender. The modifiable risk factors included psychosis, disorganized thought process, medication noncompliance, insomnia, and active substance use disorder. These were addressed by adding back his home medications and holding in a substance free environment. He was able to acknowledge that his substance use, sleeplessness, and medication nonadherence led to his decompensation. Finally, the patient is being discharged with protective risk factors, including future-oriented viewpoint, positive therapeutic relationship with outpatient providers, lack of suicidal ideation during inpatient stay, and strong social supports from family. 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. Haloperidol 20 mg PO QHS 2. Benztropine Mesylate 2 mg PO QHS 3. Lithium Carbonate 300 mg PO QAM 4. Lithium Carbonate 600 mg PO QHS 5. [MASKED] Palmitate 234 mg IM Q1MO (WE) Discharge Medications: 1. Benztropine Mesylate 2 mg PO QHS 2. Haloperidol 20 mg PO QHS 3. Lithium Carbonate 900 mg PO QHS 4. [MASKED] Palmitate 234 mg IM Q1MO (WE) Discharge Disposition: Home Discharge Diagnosis: schizoaffective disorder Discharge Condition: - Data: [MASKED] BMP, CBC w/ differential, serum toxicology, and TSH within normal limits; lithium level less than 0.2 - Exam: * VS: T 98.3F, BP 139/71, HR 90, SpO2 100% RA - Neurological: * station and gait: normal/normal * tone and strength: grossly normal, freely moves limbs * cranial nerves: II-XII grossly symmetrical * abnormal movements: none * appearance: age appearing man, spectacled, wearing sweatpants with [MASKED] shorts over them, shirt with paint on it, beanie hat, adequate hygiene and grooming, no apparent distress * behavior: calm, cooperative, pleasant * mood / affect: 'fine' with expansive affect * thought process: tangential with loosening of associations * thought content: no thoughts of self harm; no thoughts of violence; endorses chronic auditory hallucinations, endorses delusional paranoia of people hating him * judgment and Insight: poor judgment as evidenced by his discontinuation of medications and substance abuse; insight fluctuates at times acknowledging his psychosis and later in the interview stating he merely was anxious - Cognition: * attention, *orientation, and executive function: attentive to exam, oriented to self and interviewer, executive function grossly intact * memory: able to recall yesterday's events and HPI * fund of knowledge: no change * calculations: deferred * abstraction: deferred * visuospatial: deferred * speech: normal rate, prosody, volume * language: good vocabulary/syntax intact Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. *It was a pleasure to have worked with you, and we wish you the best of health.* Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "F209: Schizophrenia, unspecified", "R45851: Suicidal ideations", "R440: Auditory hallucinations", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1210: Cannabis abuse, uncomplicated", "F1590: Other stimulant use, unspecified, uncomplicated" ]
10,054,622
20,480,182
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Pelvic cramping Major Surgical or Invasive Procedure: Dilation and curettage 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: LABS ==================== ___ 03:15AM BLOOD WBC-5.5 RBC-3.07* Hgb-8.7* Hct-26.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 RDWSD-42.3 Plt Ct-87* ___ 07:16AM BLOOD WBC-6.1 RBC-2.90* Hgb-8.3* Hct-24.5* MCV-85 MCH-28.6 MCHC-33.9 RDW-13.6 RDWSD-42.4 Plt Ct-74* ___ 07:50PM BLOOD WBC-8.8 RBC-3.22* Hgb-9.3* Hct-27.0* MCV-84 MCH-28.9 MCHC-34.4 RDW-13.5 RDWSD-41.2 Plt Ct-64* ___ 02:25PM BLOOD WBC-13.5* RBC-3.51* Hgb-10.1* Hct-30.0* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 RDWSD-41.6 Plt Ct-75* ___ 08:50AM BLOOD WBC-18.5* RBC-3.94 Hgb-11.4 Hct-33.6* MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 RDWSD-41.7 Plt Ct-86* ___ 07:00PM BLOOD WBC-14.9*# RBC-3.88* Hgb-11.4 Hct-32.9* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 RDWSD-40.3 Plt Ct-92* ___ 07:16AM BLOOD Neuts-78.7* Lymphs-12.0* Monos-8.2 Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.80 AbsLymp-0.73* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 ___ 07:50PM BLOOD Neuts-73* Bands-21* Lymphs-5* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.27* AbsLymp-0.44* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 07:00PM BLOOD Neuts-84.2* Lymphs-8.7* Monos-6.1 Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.52*# AbsLymp-1.29 AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL ___ 07:50PM BLOOD Plt Smr-VERY LOW Plt Ct-64* ___ 03:15AM BLOOD Plt Ct-87* ___ 07:16AM BLOOD Plt Ct-74* ___ 02:25PM BLOOD Plt Ct-75* ___ 08:50AM BLOOD Plt Ct-86* ___ 08:50AM BLOOD ___ PTT-27.1 ___ ___ 07:00PM BLOOD Plt Smr-LOW Plt Ct-92* ___ 07:00PM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-135 K-3.5 Cl-99 HCO3-24 AnGap-16 ___ 07:00PM BLOOD Genta-<0.2* ___ 07:50PM BLOOD Lactate-1.5 ___ 09:00AM BLOOD Lactate-1.3 ___ 09:00AM BLOOD Hgb-12.3 calcHCT-37 ___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:35PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 06:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 08:30PM URINE RBC->182* WBC-6* Bacteri-FEW Yeast-NONE Epi-<1 MICROBIOLOGY ==================== ___ 9:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. ___ 7:50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 6:35 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ==================== ___ Pelvic Ultrasound Final Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: ___ G2P0 @ 12w p/w abdominal pain// eval for ___ trimester pregnancy LMP: ___ TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None. FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 62 mm representing a gestational age of 12 weeks 5 days. This corresponds satisfactorily with the menstrual dates of 12 weeks 2 days. The uterus is normal. The ovaries are normal. There is funnel shaped dilation of the cervix measuring 7 mm at its widest point, at the internal os. IMPRESSION: 1. Single live intrauterine pregnancy with size = dates. 2. Cervical dilation measuring up to 7 mm at its widest point, at the internal os. ___ Pelvic Ultrasound Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed.// ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed. TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound ___. FINDINGS: The uterus is anteverted. Previously noted gestational sac and fetus are no longer present. The endometrial cavity is distended with heterogeneous echogenic material, with vascularized products seen posteriorly at the level of the uterine body, measuring at least 5.3 x 3.8 cm in transverse ___, compatible with vascularized retained products of conception. In addition, there is heterogeneous echogenic material without vascularity in the endocervical canal concerning for blood products. Small amount of free fluid in the pelvis. Normal ovaries bilaterally. IMPRESSION: Findings consistent with vascularized retained products of conception measuring at least 5.3 x 3 8 cm in transverse ___ with additional echogenic blood products in the endocervical canal. Small amount of free fluid. Brief Hospital Course: Ms. ___ is a ___ yo G3P0 who presented to the ED at 12weeks gestational age with cramping. She underwent a pelvic ultrasound on ___ which demonstrated a live single intrauterine pregnancy. While in the ED, she developed worsening cramping and vaginal bleeding, and she passed fetal tissue. Repeat pelvic ultrasound revealed retained products of conception. In the ED, pt was noted to be tachycardic (HR max 117) with Tmax 100.2. Her labs were notable for increasing leukocytosis (14 -> 18), thought to be secondary to an inflammatory reaction to her miscarriage (differential included uterine infection i.e. endometritis). The decision was made to proceed with a dilation and curettage for complete removal of pregnancy tissue. On ___ Ms. ___ underwent an uncomplicated ultrasound-guided dilation and curettage. Please refer to the operative note for full details. She had an estimated blood loss of 350mL and received methergine and cytotec intraoperatively. She was continued on PO methergine for 24 hours post-operatively. She also received IV doxycycline intra-operatively due to concern for developing endometritis. Her hematocrit was trended: 33.6 (pre-operative) -> 30.0 (PACU) -> 24.5 (post-operative day #1)-> 26 (post-operative day #2 am). Her post-operative course was complicated by fever and thrombocytopenia: - Fever: Pt spiked a fever to 103.1 on post-operative day #1. Her CBC at the time was notable for WBC 8.8 with 21 bands. UA was negative for UTI. She was treated for presumed endometritis, and received IV gentamicin and IV clindamycin for 24 hours (___). She was then transitioned to PO doxycycline and PO flagyl. - Thrombocytopenia: Pt was noted to have downtrending platelets, with nadir of 64 (___), thought due to ITP vs. gestational thrombocytopenia. Her vaginal bleeding was minimal following the procedure, and her platelet count improved prior to discharge (platelet=87 on ___. NSAIDs were held during this admission in the setting of thrombocytopenia. Thee remainder of her post-operative course was uncomplicated. She received PO Tylenol and oxycodone prn pelvic pain. Her diet was advanced without difficulty. She voided spontaneously on post-operative day #0. By hospital day #2, pt was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was well-controlled with oral medications. She was discharged to home with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 3. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [___] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Retained products of conception 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 take more than 4000mg acetaminophen (APAP) in 24 hrs. * Please avoid NSAIDs (ex. ibuprofen) in the setting of your low platelet counts * 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. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) until your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "O030", "D696" ]
Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Pelvic cramping Major Surgical or Invasive Procedure: Dilation and curettage 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: LABS ==================== [MASKED] 03:15AM BLOOD WBC-5.5 RBC-3.07* Hgb-8.7* Hct-26.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 RDWSD-42.3 Plt Ct-87* [MASKED] 07:16AM BLOOD WBC-6.1 RBC-2.90* Hgb-8.3* Hct-24.5* MCV-85 MCH-28.6 MCHC-33.9 RDW-13.6 RDWSD-42.4 Plt Ct-74* [MASKED] 07:50PM BLOOD WBC-8.8 RBC-3.22* Hgb-9.3* Hct-27.0* MCV-84 MCH-28.9 MCHC-34.4 RDW-13.5 RDWSD-41.2 Plt Ct-64* [MASKED] 02:25PM BLOOD WBC-13.5* RBC-3.51* Hgb-10.1* Hct-30.0* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 RDWSD-41.6 Plt Ct-75* [MASKED] 08:50AM BLOOD WBC-18.5* RBC-3.94 Hgb-11.4 Hct-33.6* MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 RDWSD-41.7 Plt Ct-86* [MASKED] 07:00PM BLOOD WBC-14.9*# RBC-3.88* Hgb-11.4 Hct-32.9* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 RDWSD-40.3 Plt Ct-92* [MASKED] 07:16AM BLOOD Neuts-78.7* Lymphs-12.0* Monos-8.2 Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-4.80 AbsLymp-0.73* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 [MASKED] 07:50PM BLOOD Neuts-73* Bands-21* Lymphs-5* Monos-1* Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-8.27* AbsLymp-0.44* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* [MASKED] 07:00PM BLOOD Neuts-84.2* Lymphs-8.7* Monos-6.1 Eos-0.3* Baso-0.2 Im [MASKED] AbsNeut-12.52*# AbsLymp-1.29 AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 [MASKED] 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL [MASKED] 07:50PM BLOOD Plt Smr-VERY LOW Plt Ct-64* [MASKED] 03:15AM BLOOD Plt Ct-87* [MASKED] 07:16AM BLOOD Plt Ct-74* [MASKED] 02:25PM BLOOD Plt Ct-75* [MASKED] 08:50AM BLOOD Plt Ct-86* [MASKED] 08:50AM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 07:00PM BLOOD Plt Smr-LOW Plt Ct-92* [MASKED] 07:00PM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-135 K-3.5 Cl-99 HCO3-24 AnGap-16 [MASKED] 07:00PM BLOOD Genta-<0.2* [MASKED] 07:50PM BLOOD Lactate-1.5 [MASKED] 09:00AM BLOOD Lactate-1.3 [MASKED] 09:00AM BLOOD Hgb-12.3 calcHCT-37 [MASKED] 08:30PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:35PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 08:30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [MASKED] 06:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [MASKED] 08:30PM URINE RBC->182* WBC-6* Bacteri-FEW Yeast-NONE Epi-<1 MICROBIOLOGY ==================== [MASKED] 9:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 8:30 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. [MASKED] 7:50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [MASKED] 6:35 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ==================== [MASKED] Pelvic Ultrasound Final Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: [MASKED] G2P0 @ 12w p/w abdominal pain// eval for [MASKED] trimester pregnancy LMP: [MASKED] TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None. FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 62 mm representing a gestational age of 12 weeks 5 days. This corresponds satisfactorily with the menstrual dates of 12 weeks 2 days. The uterus is normal. The ovaries are normal. There is funnel shaped dilation of the cervix measuring 7 mm at its widest point, at the internal os. IMPRESSION: 1. Single live intrauterine pregnancy with size = dates. 2. Cervical dilation measuring up to 7 mm at its widest point, at the internal os. [MASKED] Pelvic Ultrasound Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: [MASKED] w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed.// [MASKED] w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed. TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound [MASKED]. FINDINGS: The uterus is anteverted. Previously noted gestational sac and fetus are no longer present. The endometrial cavity is distended with heterogeneous echogenic material, with vascularized products seen posteriorly at the level of the uterine body, measuring at least 5.3 x 3.8 cm in transverse [MASKED], compatible with vascularized retained products of conception. In addition, there is heterogeneous echogenic material without vascularity in the endocervical canal concerning for blood products. Small amount of free fluid in the pelvis. Normal ovaries bilaterally. IMPRESSION: Findings consistent with vascularized retained products of conception measuring at least 5.3 x 3 8 cm in transverse [MASKED] with additional echogenic blood products in the endocervical canal. Small amount of free fluid. Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo G3P0 who presented to the ED at 12weeks gestational age with cramping. She underwent a pelvic ultrasound on [MASKED] which demonstrated a live single intrauterine pregnancy. While in the ED, she developed worsening cramping and vaginal bleeding, and she passed fetal tissue. Repeat pelvic ultrasound revealed retained products of conception. In the ED, pt was noted to be tachycardic (HR max 117) with Tmax 100.2. Her labs were notable for increasing leukocytosis (14 -> 18), thought to be secondary to an inflammatory reaction to her miscarriage (differential included uterine infection i.e. endometritis). The decision was made to proceed with a dilation and curettage for complete removal of pregnancy tissue. On [MASKED] Ms. [MASKED] underwent an uncomplicated ultrasound-guided dilation and curettage. Please refer to the operative note for full details. She had an estimated blood loss of 350mL and received methergine and cytotec intraoperatively. She was continued on PO methergine for 24 hours post-operatively. She also received IV doxycycline intra-operatively due to concern for developing endometritis. Her hematocrit was trended: 33.6 (pre-operative) -> 30.0 (PACU) -> 24.5 (post-operative day #1)-> 26 (post-operative day #2 am). Her post-operative course was complicated by fever and thrombocytopenia: - Fever: Pt spiked a fever to 103.1 on post-operative day #1. Her CBC at the time was notable for WBC 8.8 with 21 bands. UA was negative for UTI. She was treated for presumed endometritis, and received IV gentamicin and IV clindamycin for 24 hours ([MASKED]). She was then transitioned to PO doxycycline and PO flagyl. - Thrombocytopenia: Pt was noted to have downtrending platelets, with nadir of 64 ([MASKED]), thought due to ITP vs. gestational thrombocytopenia. Her vaginal bleeding was minimal following the procedure, and her platelet count improved prior to discharge (platelet=87 on [MASKED]. NSAIDs were held during this admission in the setting of thrombocytopenia. Thee remainder of her post-operative course was uncomplicated. She received PO Tylenol and oxycodone prn pelvic pain. Her diet was advanced without difficulty. She voided spontaneously on post-operative day #0. By hospital day #2, pt was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was well-controlled with oral medications. She was discharged to home with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 3. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [[MASKED]] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Retained products of conception 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 take more than 4000mg acetaminophen (APAP) in 24 hrs. * Please avoid NSAIDs (ex. ibuprofen) in the setting of your low platelet counts * 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. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) until your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "D696" ]
[ "O030: Genital tract and pelvic infection following incomplete spontaneous abortion", "D696: Thrombocytopenia, unspecified" ]
10,054,634
25,928,444
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Demerol / morphine Attending: ___ Chief Complaint: generalized weakness, muscle aches, intermittent fevers, sore throat and wakes up with HA, now with + BCx Major Surgical or Invasive Procedure: TEE (___) PICC line Insertion (___) History of Present Illness: Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presents with chills, HA, and positive blood cultures. 6 weeks ago ___ developed, waxing and waning, generalized muscle aches, with subjective chills but no objective fever. bifrontal mild headache without other associated neurological signs. No recent travel other than ___ and upstate ___. No history of IVDU. He had a dental cleaning 2 weeks ago after the onset of symptoms. He did have a colonoscopy 4 days prior to developing symptoms. Per referral: Pt has gram positive cocci growing out of each anaerobic blood culture (two sets were drawn) after 14 hours. He presented with 7 weeks of headache, fatigue and myalgias. ESR=42. Has dropped his HCT to ___ yesterday from 41 on ___. I consulted with ID who recommended ED eval and likely admit for repeat cx, r/o endocarditis and imaging of head (given headache and concern for mycotic aneurysm) and abdomen to look for a source. He did have a colonoscopy with polypectomy on ___. He had dental cleaning after the onset of his sx. In the ED, initial VS were 4 98.3 92 115/70 16 98% RA . Exam notable for: Exam normal neuro, rectal heme negative ___ soft systolic murmur in RUSB. Labs showed Hgb 12.5. Imaging showed: CXR No acute cardiopulmonary process. Head CT No acute intracranial process. Received vanc/cefazolin Transfer VS were 75 122/66 18 98% RA On arrival to the floor, patient reports that he has been having myalgias and HA x 6 weeks on and off. He endorses slight fever. His HA is mild, dull, all over, and occurs in the mornings but does not wake him up. No associated photophobia, phonophobia, neck stiffness, blurry vision, dizziness, or nausea. Tylenol helps. He also endorses various wandering muscle pains but no joint pains. He was tested for lyme but it was negative and he denies tick exposure. He did have a colonoscopy around the time his sx started but denies abdominal pain, constipation, or diarrhea. HE denies chest pain or dizziness. He denies trauma or sick contacts. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: Hypercholesterolemia Rhinitis, allergic Duodenal ulcer with hemorrhage Dermatitis, seborrheic Serrated adenoma of colon Sleep disturbance BPH (benign prostatic hyperplasia) Cholecystectomy (___) Social History: ___ Family History: Mother with ___. Father with hairy cell leukemia & stroke. MI in maternal uncle and MGM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO 141 / 74 70 16 95 RA GENERAL: Pleasant, alert, NAD . Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear NECK: supple, intact chin-to-chest, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM VS: 98.4PO 116/64 R 74 18 96 Ra GENERAL: Pleasant, alert, NAD. Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear 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, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ============== ___ 02:01PM BLOOD WBC-9.3 RBC-4.24* Hgb-12.5* Hct-37.4* MCV-88 MCH-29.5 MCHC-33.4 RDW-12.3 RDWSD-39.6 Plt ___ ___ 02:01PM BLOOD Neuts-84.5* Lymphs-6.2* Monos-7.9 Eos-0.9* Baso-0.2 Im ___ AbsNeut-7.83* AbsLymp-0.57* AbsMono-0.73 AbsEos-0.08 AbsBaso-0.02 ___ 02:01PM BLOOD Glucose-112* UreaN-20 Creat-1.0 Na-136 K-5.0 Cl-100 HCO3-24 AnGap-17 ___ 02:19PM BLOOD Lactate-1.7 MICROBIOLOGY: ============== ___ 2:02 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (___) GROUP | CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by ___ @ 1255 ON ___. PATIENT CREDITED. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. ==== ___ 1:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STREPTOCOCCUS ANGINOSUS (___) GROUP. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___, ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by ___ @ 1255 ON ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ==== ___ Blood Culture, Routine (Final ___: NO GROWTH. PERTINENT IMAGING: ================ CT HEAD W/O CONTRAST: No acute intracranial process. TTE: Mildly thickened aortic valve with moderate aortic regurgitation. Myxomatous mitral leaflets with mild-moderate late systolic mitral regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. If clinically indicated, a transesophageal echocardiographic examination is recommended to better assess the aortic and mitral valve morpholgy for possible vegetations/endocarditis. TEE: Mildly thiickened aortic valve leaflets with moderate aortic regurgitation but without discrete vegetation. Mild bileaflet mitral valve prolapse with mild late systolic mitral regurgitation. DISCHARGE LABS: ============= ___ 08:20AM BLOOD WBC-7.7 RBC-4.16* Hgb-12.4* Hct-36.9* MCV-89 MCH-29.8 MCHC-33.6 RDW-12.3 RDWSD-39.8 Plt ___ ___ 03:02PM BLOOD CRP-44.3* Brief Hospital Course: Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presented with chills, myalgias, and headache, admitted with viridans strep sepsis. #VIRIDANS STREP SEPSIS: Initial cultures at ___ grew GPCs that resulted in viridans strep species. Initial blood cultures on admission to ___ ___ were also positive for viridians strep. All culture sensitivities were pan sensitive (see microbiology section for specific sensitivity data). The patient was started on vancomycin empirically and ultimately narrowed to ceftriaxone based on culture sensitivities. Etiology of GPC sepsis was unclear. TTE was negative for vegetations but showed bileaflet mitrial prolapse and aortic regurgitation. A TEE was performed that was negative for vegetations. There were no localizing symptoms. Dentition was good, though patient had previous dental instrumentation prior to admission. A Panorex was performed and the result will be followed up after discharge. A PICC was placed prior to discharge. The patient will continue CTX as an outpatient for a total course of 4 weeks (D1: ___ projected end date: ___. #Normocytic Anemia: Hgb during admission was ___. Previous baseline in ___ was 14.2. No evidence of bleeding. Hgb remained stable. Workup with iron studies if anemia does not resolve after acute illness. #Headache: Patient was experiencing intermittent headaches on admission that were relieved with Tylenol. He did not experience nausea, photo/phonophobia, blurry vision, or any worrisome signs or symptoms. A CT Head was negative. He was continued on Tylenol PRN during hospitalization. CHRONIC: #HLD: Continued home atorvastatin #BPH: Continued home tamsulosin #Seasonal allergies: Continued Flonase, Claritin ===================== TRANSITIONAL ISSUES: ===================== NEW MEDICATIONS: [ ] Ceftriaxone 2mg IV Daily for a total course of 4 weeks (D1: ___ projected end date: ___ ITEMS FOR FOLLOW-UP: [ ] Follow-up final panorex read (Date of exam: ___ [ ] Lab draw every week: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK, PHOS, CRP, ESR [ ] Infectious Disease OPAT will arrange outpatient follow-up [ ] Continue CTX as an outpatient for a total course of 4 weeks (D1: ___ projected end date: ___, or instructed by infectious disease [ ] Follow-up weekly CBC, if Hgb trending down (Hgb at discharge > 12), send for iron studies and work up. Patient has had a GI bleed in the past. [ ] ECHO showed bileaflet mitrial valve prolapse and mild aortic regurgitation. Please continue to monitor patient and consider referral to cardiology for surveillance. Name of health care proxy: ___ Relationship: wife Phone number: ___ Code: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS:PRN insomnia 2. Tamsulosin 0.4 mg PO QHS 3. Atorvastatin 20 mg PO QPM 4. Loratadine 10 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 mg IV Q24H Disp #*28 Intravenous Bag Refills:*0 2. Atorvastatin 20 mg PO QPM 3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Loratadine 10 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: -- SEPSIS, GRAM POSITIVE -- HEADACHE -- ANEMIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you! You were admitted to the hospital because you had bacteria in your blood. You were given antibiotics through your vein. You were seen by the infection doctors who recommended ___ through your vein for four weeks. We do not know what caused the infection. We looked at your heart valves with an ultrasound and did not find an infection hiding in your heart. We did a scan of your brain because of your headaches and the scan was normal. Finally, we took XRays of your mouth. The results of the mouth XRAY are pending and you will go over these results when you follow up with your regular doctors. Someone from the infectious disease department will call you to schedule a follow up appointment. If you don't hear from them in a week, you can call at ___. It was a pleasure caring for you! Sincerely, Your Medical Team Followup Instructions: ___
[ "A408", "E785", "N400", "J302", "G4700", "D649", "R51" ]
Allergies: Demerol / morphine Chief Complaint: generalized weakness, muscle aches, intermittent fevers, sore throat and wakes up with HA, now with + BCx Major Surgical or Invasive Procedure: TEE ([MASKED]) PICC line Insertion ([MASKED]) History of Present Illness: Patient is a [MASKED] M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presents with chills, HA, and positive blood cultures. 6 weeks ago [MASKED] developed, waxing and waning, generalized muscle aches, with subjective chills but no objective fever. bifrontal mild headache without other associated neurological signs. No recent travel other than [MASKED] and upstate [MASKED]. No history of IVDU. He had a dental cleaning 2 weeks ago after the onset of symptoms. He did have a colonoscopy 4 days prior to developing symptoms. Per referral: Pt has gram positive cocci growing out of each anaerobic blood culture (two sets were drawn) after 14 hours. He presented with 7 weeks of headache, fatigue and myalgias. ESR=42. Has dropped his HCT to [MASKED] yesterday from 41 on [MASKED]. I consulted with ID who recommended ED eval and likely admit for repeat cx, r/o endocarditis and imaging of head (given headache and concern for mycotic aneurysm) and abdomen to look for a source. He did have a colonoscopy with polypectomy on [MASKED]. He had dental cleaning after the onset of his sx. In the ED, initial VS were 4 98.3 92 115/70 16 98% RA . Exam notable for: Exam normal neuro, rectal heme negative [MASKED] soft systolic murmur in RUSB. Labs showed Hgb 12.5. Imaging showed: CXR No acute cardiopulmonary process. Head CT No acute intracranial process. Received vanc/cefazolin Transfer VS were 75 122/66 18 98% RA On arrival to the floor, patient reports that he has been having myalgias and HA x 6 weeks on and off. He endorses slight fever. His HA is mild, dull, all over, and occurs in the mornings but does not wake him up. No associated photophobia, phonophobia, neck stiffness, blurry vision, dizziness, or nausea. Tylenol helps. He also endorses various wandering muscle pains but no joint pains. He was tested for lyme but it was negative and he denies tick exposure. He did have a colonoscopy around the time his sx started but denies abdominal pain, constipation, or diarrhea. HE denies chest pain or dizziness. He denies trauma or sick contacts. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: Hypercholesterolemia Rhinitis, allergic Duodenal ulcer with hemorrhage Dermatitis, seborrheic Serrated adenoma of colon Sleep disturbance BPH (benign prostatic hyperplasia) Cholecystectomy ([MASKED]) Social History: [MASKED] Family History: Mother with [MASKED]. Father with hairy cell leukemia & stroke. MI in maternal uncle and MGM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO 141 / 74 70 16 95 RA GENERAL: Pleasant, alert, NAD . Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear NECK: supple, intact chin-to-chest, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM VS: 98.4PO 116/64 R 74 18 96 Ra GENERAL: Pleasant, alert, NAD. Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear 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, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ============== [MASKED] 02:01PM BLOOD WBC-9.3 RBC-4.24* Hgb-12.5* Hct-37.4* MCV-88 MCH-29.5 MCHC-33.4 RDW-12.3 RDWSD-39.6 Plt [MASKED] [MASKED] 02:01PM BLOOD Neuts-84.5* Lymphs-6.2* Monos-7.9 Eos-0.9* Baso-0.2 Im [MASKED] AbsNeut-7.83* AbsLymp-0.57* AbsMono-0.73 AbsEos-0.08 AbsBaso-0.02 [MASKED] 02:01PM BLOOD Glucose-112* UreaN-20 Creat-1.0 Na-136 K-5.0 Cl-100 HCO3-24 AnGap-17 [MASKED] 02:19PM BLOOD Lactate-1.7 MICROBIOLOGY: ============== [MASKED] 2:02 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STREPTOCOCCUS ANGINOSUS ([MASKED]) GROUP | CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by [MASKED] @ 1255 ON [MASKED]. PATIENT CREDITED. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CHAINS. ==== [MASKED] 1:45 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STREPTOCOCCUS ANGINOSUS ([MASKED]) GROUP. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [MASKED], [MASKED]. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by [MASKED] @ 1255 ON [MASKED]. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ==== [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. PERTINENT IMAGING: ================ CT HEAD W/O CONTRAST: No acute intracranial process. TTE: Mildly thickened aortic valve with moderate aortic regurgitation. Myxomatous mitral leaflets with mild-moderate late systolic mitral regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. If clinically indicated, a transesophageal echocardiographic examination is recommended to better assess the aortic and mitral valve morpholgy for possible vegetations/endocarditis. TEE: Mildly thiickened aortic valve leaflets with moderate aortic regurgitation but without discrete vegetation. Mild bileaflet mitral valve prolapse with mild late systolic mitral regurgitation. DISCHARGE LABS: ============= [MASKED] 08:20AM BLOOD WBC-7.7 RBC-4.16* Hgb-12.4* Hct-36.9* MCV-89 MCH-29.8 MCHC-33.6 RDW-12.3 RDWSD-39.8 Plt [MASKED] [MASKED] 03:02PM BLOOD CRP-44.3* Brief Hospital Course: Patient is a [MASKED] M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presented with chills, myalgias, and headache, admitted with viridans strep sepsis. #VIRIDANS STREP SEPSIS: Initial cultures at [MASKED] grew GPCs that resulted in viridans strep species. Initial blood cultures on admission to [MASKED] [MASKED] were also positive for viridians strep. All culture sensitivities were pan sensitive (see microbiology section for specific sensitivity data). The patient was started on vancomycin empirically and ultimately narrowed to ceftriaxone based on culture sensitivities. Etiology of GPC sepsis was unclear. TTE was negative for vegetations but showed bileaflet mitrial prolapse and aortic regurgitation. A TEE was performed that was negative for vegetations. There were no localizing symptoms. Dentition was good, though patient had previous dental instrumentation prior to admission. A Panorex was performed and the result will be followed up after discharge. A PICC was placed prior to discharge. The patient will continue CTX as an outpatient for a total course of 4 weeks (D1: [MASKED] projected end date: [MASKED]. #Normocytic Anemia: Hgb during admission was [MASKED]. Previous baseline in [MASKED] was 14.2. No evidence of bleeding. Hgb remained stable. Workup with iron studies if anemia does not resolve after acute illness. #Headache: Patient was experiencing intermittent headaches on admission that were relieved with Tylenol. He did not experience nausea, photo/phonophobia, blurry vision, or any worrisome signs or symptoms. A CT Head was negative. He was continued on Tylenol PRN during hospitalization. CHRONIC: #HLD: Continued home atorvastatin #BPH: Continued home tamsulosin #Seasonal allergies: Continued Flonase, Claritin ===================== TRANSITIONAL ISSUES: ===================== NEW MEDICATIONS: [ ] Ceftriaxone 2mg IV Daily for a total course of 4 weeks (D1: [MASKED] projected end date: [MASKED] ITEMS FOR FOLLOW-UP: [ ] Follow-up final panorex read (Date of exam: [MASKED] [ ] Lab draw every week: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK, PHOS, CRP, ESR [ ] Infectious Disease OPAT will arrange outpatient follow-up [ ] Continue CTX as an outpatient for a total course of 4 weeks (D1: [MASKED] projected end date: [MASKED], or instructed by infectious disease [ ] Follow-up weekly CBC, if Hgb trending down (Hgb at discharge > 12), send for iron studies and work up. Patient has had a GI bleed in the past. [ ] ECHO showed bileaflet mitrial valve prolapse and mild aortic regurgitation. Please continue to monitor patient and consider referral to cardiology for surveillance. Name of health care proxy: [MASKED] Relationship: wife Phone number: [MASKED] Code: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS:PRN insomnia 2. Tamsulosin 0.4 mg PO QHS 3. Atorvastatin 20 mg PO QPM 4. Loratadine 10 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 mg IV Q24H Disp #*28 Intravenous Bag Refills:*0 2. Atorvastatin 20 mg PO QPM 3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Loratadine 10 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: -- SEPSIS, GRAM POSITIVE -- HEADACHE -- ANEMIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you! You were admitted to the hospital because you had bacteria in your blood. You were given antibiotics through your vein. You were seen by the infection doctors who recommended [MASKED] through your vein for four weeks. We do not know what caused the infection. We looked at your heart valves with an ultrasound and did not find an infection hiding in your heart. We did a scan of your brain because of your headaches and the scan was normal. Finally, we took XRays of your mouth. The results of the mouth XRAY are pending and you will go over these results when you follow up with your regular doctors. Someone from the infectious disease department will call you to schedule a follow up appointment. If you don't hear from them in a week, you can call at [MASKED]. It was a pleasure caring for you! Sincerely, Your Medical Team Followup Instructions: [MASKED]
[]
[ "E785", "N400", "G4700", "D649" ]
[ "A408: Other streptococcal sepsis", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "J302: Other seasonal allergic rhinitis", "G4700: Insomnia, unspecified", "D649: Anemia, unspecified", "R51: Headache" ]
10,054,753
28,204,953
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weeks of nausea, vomiting, and progressively worse food and water intake. Major Surgical or Invasive Procedure: Placement of venting gastric tube History of Present Illness: Mr. ___ is a ___ M h/o colon CA s/p colectomy with end colostomy, lung CA s/p ___ transferred to ___ after a syncopal episode with headstrike. Pt had 2 weeks of n/v w/ non-bloody, slightly green emesis. Stools appeared more liquidy in ostomy bad but were non-bloody. Pt's PO intake became progressively worse and son reports him looking progressively fatigued and taking in very little food or water by the end of the 2 weeks. This was accompanied by ___ lb weight loss. Pt also developed neck pain recently. Pt also developed cough productive for clear phlegm (no hemoptysis) and has had shortness of breath. No fevers, chills, night sweats, headaches, numbness/tingling, sensory disturbances, focal motor issues, seizures, chest pain, back pain, abdominal pain, calf pain, or swelling. During this time, he developed several days of light-headedness and was taking a shower when the light-headedness worsened and he passed out with headstrike. No history of prior thrombotic/clotting episodes. At OSH, he was hypothermic with elevated lactate (3.3) and leukocytosis (WBC 18.3). CT head was negative. CT chest revealed potential pneumonia vs scarring. EKG was notable for sinus tachycardia with diffuse ST depressions (not pt's baseline). He was fluid resuscitated and given cefepime at the outside hospital. He was transferred to ___ where his lactate was 1.6. His CT studies were concerning for SBO and revealed a C7 compression fracture w/ lytic lesions, and paraspinal lesion that could be metastasis or abscess. He was given vanc and zosyn for suspected infection and sepsis as his WBC was 20. Pt was admitted to ___ for his SBO and managed conservatively as pt was poor surgical candidate given malignancy. NGT placed and pt responded well with decreased n/v. Now s/p NGT removal, pt is being transferred to the floor for further coordination of care and management of C7 compression fracture and paraspinal lesion. On the floor, pt is tired but mood is not depressed. Reports nausea and vomiting resolved, no abdominal pain. Has not passed flatus. No fevers or chills. No difficulty breathing. No neck pain. No numbness or tingling. Past Medical History: Diabetes mellitus Lung cancer s/p lobectomy, on Tarceva for lung cancer (started in ___. Colon cancer s/p colectomy with end colostomy (about ___ years ago). Social History: ___ Family History: Grandmother - thyroid cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS - 97.9-98.7, 83/46 - 116/63, 74-91, ___, 96-100 RA, I/O: ___ GENERAL - Tired, but non-toxic, pleasant. HEENT - 2 cm linear healed laceration near R eye. Sclerae anicteric, MMM, oropharynx clear. NECK - In neck brace. CARDIAC - RRR, S1, S2, no r/m/g LUNGS - Anterior regions CTAB. ABDOMEN - +BS, soft, non-tender throughout to deep palpation, ostomy bag full of greenish, soft stool. EXTREMITIES - WWP, 2+ pulses, no edema, no calf tenderness. NEUROLOGIC - AAOx3, EOMI, PERRLA (pupils have small response bilaterally), pt can stick out tongue, open mouth, sensation grossly intact, upper and lower extremities ___ on strength. DISCHARGE PHYSICAL EXAM: ======================== Vitals: I/O: 97.7PO 110 / 65 76 18 96 Ra General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: In brace Lungs: CTAB CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Ostomy bag not producing any stool. G tube bag with greenish fluid. GU: no foley Ext: WWP, no edema Neuro: motor function, sensorium grossly normal. alert and oriented Vitals: 97.5-98.4 114/70 - 126/60 ___ RA I/O: 2451/___ (350 gtube) General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: In brace Lungs: CTAB CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Ostomy bag not producing any stool. G tube bag with greenish fluid. GU: no foley Ext: WWP, 2+ pulses, no edema Neuro: CNs2-12 intact, motor function, sensorium grossly normal. Pertinent Results: ADMISSION LABS: ___ 01:45AM BLOOD WBC-20.2* RBC-4.47* Hgb-11.4* Hct-33.5* MCV-75* MCH-25.5* MCHC-34.0 RDW-17.6* RDWSD-46.6* Plt ___ ___ 01:45AM BLOOD Neuts-84.7* Lymphs-7.0* Monos-7.6 Eos-0.1* Baso-0.1 Im ___ AbsNeut-17.05* AbsLymp-1.41 AbsMono-1.54* AbsEos-0.02* AbsBaso-0.03 ___ 01:45AM BLOOD ___ PTT-30.1 ___ ___ 09:23AM BLOOD ___ 01:45AM BLOOD Glucose-126* UreaN-35* Creat-1.0 Na-131* K-2.6* Cl-88* HCO3-30 AnGap-16 ___ 01:45AM BLOOD ALT-23 AST-25 AlkPhos-119 TotBili-3.3* ___ 01:45AM BLOOD Lipase-75* ___ 01:45AM BLOOD proBNP-551* ___ 01:45AM BLOOD cTropnT-<0.01 ___ 01:45AM BLOOD Albumin-3.2* Calcium-8.0* Phos-2.7 Mg-2.3 ___ 01:50AM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 05:39AM BLOOD WBC-5.9 RBC-3.42* Hgb-8.7* Hct-28.5* MCV-83 MCH-25.4* MCHC-30.5* RDW-18.7* RDWSD-55.8* Plt ___ ___ 05:39AM BLOOD Glucose-126* UreaN-9 Creat-1.0 Na-144 K-3.7 Cl-109* HCO3-29 AnGap-10 ___ 05:39AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.5 MICROBIOLOGY: Urine, 2x blood cultures: final: no growth Paraspinal fluid collection culture: final: no growth, preliminary: no anaerobic or fungal growth IMAGING: ___ CT Abdomen and pelvis with IV contrast COMPARISON: None. FINDINGS: LOWER CHEST: Large nodules in the left lower lobe measure 11 and 16 mm, consistent with metastasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Ill defined hypodensities with peripheral heterogeneous hyperenhancement are consistent with metastasis. For example, in the hepatic dome measuring 15 mm and 36 mm (2:9) and left hepatic lobe measuring 20 mm (2:21). 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: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in 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 esophagus is dilated with hyperenhancement of the mucosa. The stomach is unremarkable. Small bowel loops are dilated to 4.4 cm with obstructing soft tissue mass in the right abdomen measuring 3.1 x 2.2 cm, likely a peritoneal metastatic implant (2:52). Normal wall thickness and enhancement throughout. No evidence of pneumotosis, pneumoperitoneum, or perforation. Post low anterior resection with colostomy in the left anterior abdomen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: A right aortocaval lymph node measures 11 mm in short axis (2:50). There is no mesenteric lymphadenopathy, pelvic, or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Colostomy in the left anterior abdomen. In the left paraspinal muscle at the level of L3, a centrally hypodense, peripherally enhancing lesions measures 1.1 x 1.6 x 3.1 cm (2:51). IMPRESSION: 1. Malignant small bowel obstruction with obstructing soft tissue mass in the right abdomen, likely a peritoneal metastatic implant. No pneumatosis or evidence of perforation. 2. Hepatic and pulmonary lesions consistent with metastasis. Portocaval lymphadenopathy suggests nodal disease. 3. Left paraspinal lesion could represent metastasis or abscess. 4. Esophagitis. Distended fluid filled stomach. ___ TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: CT dated earlier same day. FINDINGS: Mildly dilated bowel loops are seen, with fluid-filled bowel loops in the left upper quadrant. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. An enteric tube is seen, with tip projecting over the first portion of the duodenum. IMPRESSION: Mildly dilated bowel loops, with fluid-filled loops in the left upper quadrant. No high-grade obstruction is seen in this image. ___ EXAMINATION: CT ___ W/O CONTRAST COMPARISON: Outside CT chest ___. FINDINGS: Alignment is normal. Redemonstration of the pathologic C7 vertebral body fracture with lytic lesions involving bilateral pedicles, left greater than right, bilateral lamina, and spinous process as well as the posterior aspect of the vertebral body. There is a nondisplaced fracture the posterior aspect of the C7 vertebral body to the right of the midline (601; 33). These fractures overall appear acute to subacute with suggestion of bony remodeling. Multilevel degenerative changes are identified most severe at C5-C6 with intervertebral disc height loss, vacuum phenomenon, osteophyte formation, and uncovertebral hypertrophy. There is mild spinal canal narrowing and mild-to-moderate neural foraminal narrowing from C4-C5 to C5-C6.There is no prevertebral edema. The partially visualized thyroid is unremarkable. Partially visualized left lung apices demonstrate mild apical scarring. Nasogastric tube partially visualized. IMPRESSION: 1. Lytic destructive process involving the posterior aspect of the vertebral body, bilateral pedicles, lamina common spinous process concerning for metastatic disease. Nondisplaced pathologic fracture the posterior aspect of the C7 vertebral body as well as comminuted pathologic fracture of the spinous process. These fractures appear acute to subacute with suggestion of bony remodeling of the spinous process. 2. No malalignment or prevertebral edema. ___: EXAMINATION: MR ___ AND W/O CONTRAST ___ MR ___ SPINE COMPARISON: CT cervical spine ___ FINDINGS: Again seen is a fracture involving C7 vertebral body, extending into the bilateral pedicles, lamina, and spinous process, better delineated on recent CT cervical spine dated ___. There is corresponding STIR hyperintensity and T1 hypointensity suggesting acute to subacute fracture. There is enhancement of the vertebral body and posterior elements with soft tissue mass surrounding the spinous process of C7 vertebral body (08:28) measuring 2.3 cm x 2.2 cm. There is mild circumferential epidural soft tissue enhancement seen at this level with mild indentation on the thecal sac without high-grade spinal cord compression. Focal enhancing lesion within the right transverse process of C1 sulcal visualized (08:29). The alignment of cervical spine is otherwise maintained. The remaining vertebral body heights and intervertebral disc space are preserved. There are mild degenerative changes with disc protrusions at C4-C5, C5-C6, C6-C7 causing mild spinal canal stenosis with mild bilateral neural foraminal narrowing at C5-C6 and C6-C7 levels. The prevertebral and craniocervical junction appear unremarkable. IMPRESSION: 1. Redemonstration of an acute to subacute fracture involving C7 vertebral body and posterior elements with an associated soft tissue mass involving the C7 spinous process suggestive of a pathologic fracture likely metastatic disease. There is circumferential epidural soft tissue at C7 level with mild compression of the thecal sac without high-grade spinal cord compression. 2. No evidence of cord compression or cord edema. 3. Mild cervical spondylosis. ___: TECHNIQUE: Portable supine and upright abdominal radiographs were obtained. COMPARISON: Abdominal radiograph dated ___. FINDINGS: There is an extremely dilated stomach, and multiple loops of dilated small bowel with air fluid levels. There has been interval removal of NG tube. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Atelectasis and pleural effusion are seen in the right lower lung field. An ET tube is partially visualized. IMPRESSION: Extremely dilated stomach, with multiple loops of dilated small bowel and air-fluid levels consistent with persistent partial obstruction. ___: COMPARISON: CT abdomen and pelvis ___ PROCEDURE: CT-guided drainage of left paraspinal collection. TECHNIQUE: Using intermittent CT fluoroscopic guidance, an 17 gauge coaxial needle was advanced into the collection. Approximately 6 cc of blood was aspirated and sent for culture. The procedure was tolerated well, and there were no immediate post-procedural complications. FINDINGS: Preprocedure CT re-demonstrates a hypoattenuating collection in the left psoas muscle, medially adjacent to the vertebral body. Intraprocedural CT fluoroscopy demonstrates appropriate positioning of the coaxial needle. IMPRESSION: Successful CT-guided aspiration of a left paraspinal collection. Approximately 6 cc blood was aspirated and sent for culture. Brief Hospital Course: Mr. ___ is a ___ year old man with a history of colon cancer s/p colectomy with end colostomy, lung cancer s/p ___ transferred to ___ after a presyncopal episode with headstrike, and found to have a malignant SBO (now s/p venting g-tube) and C7 compression fracture. Patient and family expressed wishes to return home with hospice care. ACTIVE ISSUES: =============== #Goals of care: Pt has a history of colon cancer and lung cancer was found to have an unresolving malignant bowel obstruction not amenable to surgical or chemotherapeutic debulking, and a venting G-tube was placed for comfort (see below). Patient expressed an understanding of the severity of his current medical condition and the fact that there was no curative treatment at this point. Patient expressed his wish to go home with hospice care. He wished to be with his family at home. MOLST was reviewed with the patient and family. Mr. ___ confirmed that he would like to be DNAR/DNI, but would like to return to the hospital if needed. Patient discharged home with hospice care. #Malignant complete SBO: Patient has a history of colorectal cancer and lung cancer who presented initially to an outside hospital with weeks of nausea and vomiting and poor oral intake. Imaging was notable for small bowel obstruction by a suspected malignant mass (likely colon cancer). Patient responded well to NGT decompression and Zofran, with resolving nausea and vomiting, but patient could not tolerate removal of the NGT. Patient eventually stopped producing material in the ostomy bag, concerning for a complete bowel obstruction. Surgery and his outpatient oncologist were consulted. Because it was determined that the patient was not a candidate for further surgical cancer reduction and because the obstructing malignancy could not be effectively treated through chemotherapy, a venting G-tube was placed to facilitate management of his obstruction. Patient was stable at the time of discharge and comfortable with the venting G-tube. #Paraspinal lesion: Patient was found to have a paraspinal lesion on imaging upon admission that was most likely secondary to a metastatic process. He had ___ drainage of the lesion and cultures were negative with patient reporting no neurological sequelae. #C7 compression fracture: Patient was found to have a C7 compression fracture that appeared to be lytic and likely secondary to metastasis. Neurosurgery was consulted and patient was placed in a neck brace during his hospital stay without issue. Patient expressed a desire after the family meeting for the neck brace to be removed and expressed understanding of the small risk of removing the neck brace. # Reactive leukocytosis: Upon admission to the outside hospital, patient found to have leukocytosis, which was ultimately thought to be likely reactive and secondary to his volume depletion. Although patient did not have clear clinical signs of infection, he was initially started on broad spectrum antibiotics, but his infectious workup was unrevealing and patient remained afebrile during his admission so antibiotics were discontinued. #Hypernatremia: Developed hypernatremia in the setting of malignant small bowel obstruction, which improved with free water. #Presyncope: Patient developed presyncopal symptoms prior to admission likely secondary to orthostasis in the setting of poor oral intake and persistent nausea and vomiting with small bowel obstruction. Patient was without further presyncopal events after fluid resuscitation and during the remainder of his hospital stay. TRANSITIONAL ISSUES: ==================== 1. Patient should be managed at home with hospice care and with a focus on comfort measures. 2. Patient does not need to have neck brace on at home (per patient preference) but should avoid strenuous activity or heavy-lifting. # CODE: DNR/DNI (confirmed) # CONTACT: ___ (son) ___ Name of health care proxy: ___: Wife Cell phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Erlotinib 150 mg PO DAILY 2. Ondansetron ODT 8 mg PO Q8H:PRN nausea 3. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea 4. Mirtazapine 15 mg PO QHS 5. Ferrous Sulfate 325 mg PO DAILY 6. sodium chloride 0.9 % topical DAILY Discharge Medications: 1. Ondansetron ODT 4 mg PO Q8H:PRN nausea 2. Mirtazapine 15 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Malignant complete small bowel obstruction C7 lytic fracture Paraspinal fluid collection Secondary: Colorectal cancer Lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a true pleasure caring for you at ___. You were admitted to the hospital after you had a fainting episode. You were found to have a bowel obstruction caused by your cancer and a cervical spinal fracture. Alleviation of the nausea and vomiting from the complete small bowel obstruction was managed initially with a nasogastric tube and then ultimately a venting gastric tube. Your C7 spinal fracture was managed by the neurosurgery spine team and a neck brace was placed, but ultimately removed. During the later portion of your admission, a family meeting was held with you, your son ___, your wife ___ ___, palliative care, and your medicine team, and you expressed wishes to be discharged home with hospice care. At home, without the neck brace, it is important that you do not engage in strenuous physical activity or heavy-lifting to prevent any further damage to your spine. Please see below for your upcoming appointments. Thank you for allowing us to take part in your care. Sincerely, Your ___ team Followup Instructions: ___
[ "E43", "E870", "C7951", "C7989", "M8458XA", "E869", "C3492", "E119", "F17210", "I951", "Z66", "E876", "Z6821", "Z933", "Z808", "Z85038" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weeks of nausea, vomiting, and progressively worse food and water intake. Major Surgical or Invasive Procedure: Placement of venting gastric tube History of Present Illness: Mr. [MASKED] is a [MASKED] M h/o colon CA s/p colectomy with end colostomy, lung CA s/p [MASKED] transferred to [MASKED] after a syncopal episode with headstrike. Pt had 2 weeks of n/v w/ non-bloody, slightly green emesis. Stools appeared more liquidy in ostomy bad but were non-bloody. Pt's PO intake became progressively worse and son reports him looking progressively fatigued and taking in very little food or water by the end of the 2 weeks. This was accompanied by [MASKED] lb weight loss. Pt also developed neck pain recently. Pt also developed cough productive for clear phlegm (no hemoptysis) and has had shortness of breath. No fevers, chills, night sweats, headaches, numbness/tingling, sensory disturbances, focal motor issues, seizures, chest pain, back pain, abdominal pain, calf pain, or swelling. During this time, he developed several days of light-headedness and was taking a shower when the light-headedness worsened and he passed out with headstrike. No history of prior thrombotic/clotting episodes. At OSH, he was hypothermic with elevated lactate (3.3) and leukocytosis (WBC 18.3). CT head was negative. CT chest revealed potential pneumonia vs scarring. EKG was notable for sinus tachycardia with diffuse ST depressions (not pt's baseline). He was fluid resuscitated and given cefepime at the outside hospital. He was transferred to [MASKED] where his lactate was 1.6. His CT studies were concerning for SBO and revealed a C7 compression fracture w/ lytic lesions, and paraspinal lesion that could be metastasis or abscess. He was given vanc and zosyn for suspected infection and sepsis as his WBC was 20. Pt was admitted to [MASKED] for his SBO and managed conservatively as pt was poor surgical candidate given malignancy. NGT placed and pt responded well with decreased n/v. Now s/p NGT removal, pt is being transferred to the floor for further coordination of care and management of C7 compression fracture and paraspinal lesion. On the floor, pt is tired but mood is not depressed. Reports nausea and vomiting resolved, no abdominal pain. Has not passed flatus. No fevers or chills. No difficulty breathing. No neck pain. No numbness or tingling. Past Medical History: Diabetes mellitus Lung cancer s/p lobectomy, on Tarceva for lung cancer (started in [MASKED]. Colon cancer s/p colectomy with end colostomy (about [MASKED] years ago). Social History: [MASKED] Family History: Grandmother - thyroid cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS - 97.9-98.7, 83/46 - 116/63, 74-91, [MASKED], 96-100 RA, I/O: [MASKED] GENERAL - Tired, but non-toxic, pleasant. HEENT - 2 cm linear healed laceration near R eye. Sclerae anicteric, MMM, oropharynx clear. NECK - In neck brace. CARDIAC - RRR, S1, S2, no r/m/g LUNGS - Anterior regions CTAB. ABDOMEN - +BS, soft, non-tender throughout to deep palpation, ostomy bag full of greenish, soft stool. EXTREMITIES - WWP, 2+ pulses, no edema, no calf tenderness. NEUROLOGIC - AAOx3, EOMI, PERRLA (pupils have small response bilaterally), pt can stick out tongue, open mouth, sensation grossly intact, upper and lower extremities [MASKED] on strength. DISCHARGE PHYSICAL EXAM: ======================== Vitals: I/O: 97.7PO 110 / 65 76 18 96 Ra General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: In brace Lungs: CTAB CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Ostomy bag not producing any stool. G tube bag with greenish fluid. GU: no foley Ext: WWP, no edema Neuro: motor function, sensorium grossly normal. alert and oriented Vitals: 97.5-98.4 114/70 - 126/60 [MASKED] RA I/O: 2451/[MASKED] (350 gtube) General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: In brace Lungs: CTAB CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Ostomy bag not producing any stool. G tube bag with greenish fluid. GU: no foley Ext: WWP, 2+ pulses, no edema Neuro: CNs2-12 intact, motor function, sensorium grossly normal. Pertinent Results: ADMISSION LABS: [MASKED] 01:45AM BLOOD WBC-20.2* RBC-4.47* Hgb-11.4* Hct-33.5* MCV-75* MCH-25.5* MCHC-34.0 RDW-17.6* RDWSD-46.6* Plt [MASKED] [MASKED] 01:45AM BLOOD Neuts-84.7* Lymphs-7.0* Monos-7.6 Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-17.05* AbsLymp-1.41 AbsMono-1.54* AbsEos-0.02* AbsBaso-0.03 [MASKED] 01:45AM BLOOD [MASKED] PTT-30.1 [MASKED] [MASKED] 09:23AM BLOOD [MASKED] 01:45AM BLOOD Glucose-126* UreaN-35* Creat-1.0 Na-131* K-2.6* Cl-88* HCO3-30 AnGap-16 [MASKED] 01:45AM BLOOD ALT-23 AST-25 AlkPhos-119 TotBili-3.3* [MASKED] 01:45AM BLOOD Lipase-75* [MASKED] 01:45AM BLOOD proBNP-551* [MASKED] 01:45AM BLOOD cTropnT-<0.01 [MASKED] 01:45AM BLOOD Albumin-3.2* Calcium-8.0* Phos-2.7 Mg-2.3 [MASKED] 01:50AM BLOOD Lactate-1.3 DISCHARGE LABS: [MASKED] 05:39AM BLOOD WBC-5.9 RBC-3.42* Hgb-8.7* Hct-28.5* MCV-83 MCH-25.4* MCHC-30.5* RDW-18.7* RDWSD-55.8* Plt [MASKED] [MASKED] 05:39AM BLOOD Glucose-126* UreaN-9 Creat-1.0 Na-144 K-3.7 Cl-109* HCO3-29 AnGap-10 [MASKED] 05:39AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.5 MICROBIOLOGY: Urine, 2x blood cultures: final: no growth Paraspinal fluid collection culture: final: no growth, preliminary: no anaerobic or fungal growth IMAGING: [MASKED] CT Abdomen and pelvis with IV contrast COMPARISON: None. FINDINGS: LOWER CHEST: Large nodules in the left lower lobe measure 11 and 16 mm, consistent with metastasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Ill defined hypodensities with peripheral heterogeneous hyperenhancement are consistent with metastasis. For example, in the hepatic dome measuring 15 mm and 36 mm (2:9) and left hepatic lobe measuring 20 mm (2:21). 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: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in 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 esophagus is dilated with hyperenhancement of the mucosa. The stomach is unremarkable. Small bowel loops are dilated to 4.4 cm with obstructing soft tissue mass in the right abdomen measuring 3.1 x 2.2 cm, likely a peritoneal metastatic implant (2:52). Normal wall thickness and enhancement throughout. No evidence of pneumotosis, pneumoperitoneum, or perforation. Post low anterior resection with colostomy in the left anterior abdomen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: A right aortocaval lymph node measures 11 mm in short axis (2:50). There is no mesenteric lymphadenopathy, pelvic, or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Colostomy in the left anterior abdomen. In the left paraspinal muscle at the level of L3, a centrally hypodense, peripherally enhancing lesions measures 1.1 x 1.6 x 3.1 cm (2:51). IMPRESSION: 1. Malignant small bowel obstruction with obstructing soft tissue mass in the right abdomen, likely a peritoneal metastatic implant. No pneumatosis or evidence of perforation. 2. Hepatic and pulmonary lesions consistent with metastasis. Portocaval lymphadenopathy suggests nodal disease. 3. Left paraspinal lesion could represent metastasis or abscess. 4. Esophagitis. Distended fluid filled stomach. [MASKED] TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: CT dated earlier same day. FINDINGS: Mildly dilated bowel loops are seen, with fluid-filled bowel loops in the left upper quadrant. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. An enteric tube is seen, with tip projecting over the first portion of the duodenum. IMPRESSION: Mildly dilated bowel loops, with fluid-filled loops in the left upper quadrant. No high-grade obstruction is seen in this image. [MASKED] EXAMINATION: CT [MASKED] W/O CONTRAST COMPARISON: Outside CT chest [MASKED]. FINDINGS: Alignment is normal. Redemonstration of the pathologic C7 vertebral body fracture with lytic lesions involving bilateral pedicles, left greater than right, bilateral lamina, and spinous process as well as the posterior aspect of the vertebral body. There is a nondisplaced fracture the posterior aspect of the C7 vertebral body to the right of the midline (601; 33). These fractures overall appear acute to subacute with suggestion of bony remodeling. Multilevel degenerative changes are identified most severe at C5-C6 with intervertebral disc height loss, vacuum phenomenon, osteophyte formation, and uncovertebral hypertrophy. There is mild spinal canal narrowing and mild-to-moderate neural foraminal narrowing from C4-C5 to C5-C6.There is no prevertebral edema. The partially visualized thyroid is unremarkable. Partially visualized left lung apices demonstrate mild apical scarring. Nasogastric tube partially visualized. IMPRESSION: 1. Lytic destructive process involving the posterior aspect of the vertebral body, bilateral pedicles, lamina common spinous process concerning for metastatic disease. Nondisplaced pathologic fracture the posterior aspect of the C7 vertebral body as well as comminuted pathologic fracture of the spinous process. These fractures appear acute to subacute with suggestion of bony remodeling of the spinous process. 2. No malalignment or prevertebral edema. [MASKED]: EXAMINATION: MR [MASKED] AND W/O CONTRAST [MASKED] MR [MASKED] SPINE COMPARISON: CT cervical spine [MASKED] FINDINGS: Again seen is a fracture involving C7 vertebral body, extending into the bilateral pedicles, lamina, and spinous process, better delineated on recent CT cervical spine dated [MASKED]. There is corresponding STIR hyperintensity and T1 hypointensity suggesting acute to subacute fracture. There is enhancement of the vertebral body and posterior elements with soft tissue mass surrounding the spinous process of C7 vertebral body (08:28) measuring 2.3 cm x 2.2 cm. There is mild circumferential epidural soft tissue enhancement seen at this level with mild indentation on the thecal sac without high-grade spinal cord compression. Focal enhancing lesion within the right transverse process of C1 sulcal visualized (08:29). The alignment of cervical spine is otherwise maintained. The remaining vertebral body heights and intervertebral disc space are preserved. There are mild degenerative changes with disc protrusions at C4-C5, C5-C6, C6-C7 causing mild spinal canal stenosis with mild bilateral neural foraminal narrowing at C5-C6 and C6-C7 levels. The prevertebral and craniocervical junction appear unremarkable. IMPRESSION: 1. Redemonstration of an acute to subacute fracture involving C7 vertebral body and posterior elements with an associated soft tissue mass involving the C7 spinous process suggestive of a pathologic fracture likely metastatic disease. There is circumferential epidural soft tissue at C7 level with mild compression of the thecal sac without high-grade spinal cord compression. 2. No evidence of cord compression or cord edema. 3. Mild cervical spondylosis. [MASKED]: TECHNIQUE: Portable supine and upright abdominal radiographs were obtained. COMPARISON: Abdominal radiograph dated [MASKED]. FINDINGS: There is an extremely dilated stomach, and multiple loops of dilated small bowel with air fluid levels. There has been interval removal of NG tube. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Atelectasis and pleural effusion are seen in the right lower lung field. An ET tube is partially visualized. IMPRESSION: Extremely dilated stomach, with multiple loops of dilated small bowel and air-fluid levels consistent with persistent partial obstruction. [MASKED]: COMPARISON: CT abdomen and pelvis [MASKED] PROCEDURE: CT-guided drainage of left paraspinal collection. TECHNIQUE: Using intermittent CT fluoroscopic guidance, an 17 gauge coaxial needle was advanced into the collection. Approximately 6 cc of blood was aspirated and sent for culture. The procedure was tolerated well, and there were no immediate post-procedural complications. FINDINGS: Preprocedure CT re-demonstrates a hypoattenuating collection in the left psoas muscle, medially adjacent to the vertebral body. Intraprocedural CT fluoroscopy demonstrates appropriate positioning of the coaxial needle. IMPRESSION: Successful CT-guided aspiration of a left paraspinal collection. Approximately 6 cc blood was aspirated and sent for culture. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with a history of colon cancer s/p colectomy with end colostomy, lung cancer s/p [MASKED] transferred to [MASKED] after a presyncopal episode with headstrike, and found to have a malignant SBO (now s/p venting g-tube) and C7 compression fracture. Patient and family expressed wishes to return home with hospice care. ACTIVE ISSUES: =============== #Goals of care: Pt has a history of colon cancer and lung cancer was found to have an unresolving malignant bowel obstruction not amenable to surgical or chemotherapeutic debulking, and a venting G-tube was placed for comfort (see below). Patient expressed an understanding of the severity of his current medical condition and the fact that there was no curative treatment at this point. Patient expressed his wish to go home with hospice care. He wished to be with his family at home. MOLST was reviewed with the patient and family. Mr. [MASKED] confirmed that he would like to be DNAR/DNI, but would like to return to the hospital if needed. Patient discharged home with hospice care. #Malignant complete SBO: Patient has a history of colorectal cancer and lung cancer who presented initially to an outside hospital with weeks of nausea and vomiting and poor oral intake. Imaging was notable for small bowel obstruction by a suspected malignant mass (likely colon cancer). Patient responded well to NGT decompression and Zofran, with resolving nausea and vomiting, but patient could not tolerate removal of the NGT. Patient eventually stopped producing material in the ostomy bag, concerning for a complete bowel obstruction. Surgery and his outpatient oncologist were consulted. Because it was determined that the patient was not a candidate for further surgical cancer reduction and because the obstructing malignancy could not be effectively treated through chemotherapy, a venting G-tube was placed to facilitate management of his obstruction. Patient was stable at the time of discharge and comfortable with the venting G-tube. #Paraspinal lesion: Patient was found to have a paraspinal lesion on imaging upon admission that was most likely secondary to a metastatic process. He had [MASKED] drainage of the lesion and cultures were negative with patient reporting no neurological sequelae. #C7 compression fracture: Patient was found to have a C7 compression fracture that appeared to be lytic and likely secondary to metastasis. Neurosurgery was consulted and patient was placed in a neck brace during his hospital stay without issue. Patient expressed a desire after the family meeting for the neck brace to be removed and expressed understanding of the small risk of removing the neck brace. # Reactive leukocytosis: Upon admission to the outside hospital, patient found to have leukocytosis, which was ultimately thought to be likely reactive and secondary to his volume depletion. Although patient did not have clear clinical signs of infection, he was initially started on broad spectrum antibiotics, but his infectious workup was unrevealing and patient remained afebrile during his admission so antibiotics were discontinued. #Hypernatremia: Developed hypernatremia in the setting of malignant small bowel obstruction, which improved with free water. #Presyncope: Patient developed presyncopal symptoms prior to admission likely secondary to orthostasis in the setting of poor oral intake and persistent nausea and vomiting with small bowel obstruction. Patient was without further presyncopal events after fluid resuscitation and during the remainder of his hospital stay. TRANSITIONAL ISSUES: ==================== 1. Patient should be managed at home with hospice care and with a focus on comfort measures. 2. Patient does not need to have neck brace on at home (per patient preference) but should avoid strenuous activity or heavy-lifting. # CODE: DNR/DNI (confirmed) # CONTACT: [MASKED] (son) [MASKED] Name of health care proxy: [MASKED]: Wife Cell phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Erlotinib 150 mg PO DAILY 2. Ondansetron ODT 8 mg PO Q8H:PRN nausea 3. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea 4. Mirtazapine 15 mg PO QHS 5. Ferrous Sulfate 325 mg PO DAILY 6. sodium chloride 0.9 % topical DAILY Discharge Medications: 1. Ondansetron ODT 4 mg PO Q8H:PRN nausea 2. Mirtazapine 15 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Malignant complete small bowel obstruction C7 lytic fracture Paraspinal fluid collection Secondary: Colorectal cancer Lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a true pleasure caring for you at [MASKED]. You were admitted to the hospital after you had a fainting episode. You were found to have a bowel obstruction caused by your cancer and a cervical spinal fracture. Alleviation of the nausea and vomiting from the complete small bowel obstruction was managed initially with a nasogastric tube and then ultimately a venting gastric tube. Your C7 spinal fracture was managed by the neurosurgery spine team and a neck brace was placed, but ultimately removed. During the later portion of your admission, a family meeting was held with you, your son [MASKED], your wife [MASKED] [MASKED], palliative care, and your medicine team, and you expressed wishes to be discharged home with hospice care. At home, without the neck brace, it is important that you do not engage in strenuous physical activity or heavy-lifting to prevent any further damage to your spine. Please see below for your upcoming appointments. Thank you for allowing us to take part in your care. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "E119", "F17210", "Z66" ]
[ "E43: Unspecified severe protein-calorie malnutrition", "E870: Hyperosmolality and hypernatremia", "C7951: Secondary malignant neoplasm of bone", "C7989: Secondary malignant neoplasm of other specified sites", "M8458XA: Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture", "E869: Volume depletion, unspecified", "C3492: Malignant neoplasm of unspecified part of left bronchus or lung", "E119: Type 2 diabetes mellitus without complications", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I951: Orthostatic hypotension", "Z66: Do not resuscitate", "E876: Hypokalemia", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z933: Colostomy status", "Z808: Family history of malignant neoplasm of other organs or systems", "Z85038: Personal history of other malignant neoplasm of large intestine" ]
10,054,992
25,004,394
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Paranoia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. ___ is a ___ year old female, with prior history of Bipolar Disorder / Psychosis, now presenting with acute agitation. Patient with potentially prior late diagnosis of Bipolar Disorder / Psychosis? was previously living in ___ for the past year, and returned to ___ because of mental status changes. 6 weeks prior, Husband reports that she had become depressed secondary to potentially stress. She was also drinking alcohol, and she was being self-medicated with lorazepam and Haldol (which she had been previously described before). She now is a "basket case", and feels more paranoid and has potentially lost perception with reality. Patient thinks that everyone is against her. Her husband notes that she can be somewhat aggressive sometimes. She does endorse "emptiness" in her head, and her husband believes that she may have suffered several strokes in the past as well. She does not have any headaches, numbness/tingling, focal neurological deficits, or loss of function. Patient was first evaluated and found to have potentially an exacerbation of bipolar disorder vs. alcohol use vs. organic neurologic process. Patient was then evaluated to potentially need geriatric psych management. Past Psychiatry History: Reviewed in OMR. Patient was initially diagnosed with a bipolar disorder and had a psychotic break a few years ago. At that time, she was treated with Haldol and Ativan, and had somewhat improvement. Patient was then potentially tailored off medications, and then went into a "manic phase" that lasted ? "about a year". Patient was very energetic previously, and then mood stable. She was also drinking alcohol at that time. Last year, she and her husband then moved to ___ for financial reasons and returned to the ___ because of mental status changes. In the ED, initial vitals: 97.9 76 125/81 16 98% RA Labs were significant for: Sodium 145, Potassium 3.6, BUN 24, Cr 0.7. Serum Tox pending. TSH 1.3. Vitamin B12: Pending. Hgb 11.1. CT Head Imaging without contrast showed no acute intracranial abnormality. In the ED, she received: ___ 12:27 PO Lorazepam 1 mg Vitals prior to transfer: UA 97.9 72 124/78 18 100% RA Currently, patient is standing in the room, refusing all care. Patient states that she would like to leave the hospital. Patient states that she feels that she is being kept here against her will. ROS: Unable to assess. Patient is not able to assess. Past Medical History: 1. Bipolar Disorder, Psychotic Break Social History: ___ Family History: Declines answering questions. Physical Exam: >> ADMISSION PHYSICAL EXAM: GEN: Patient is refusing to acknowledge name, date of birth or place. She continues to state that she does not need to be here. Patient also continues to state that she would like to leave. HEENT: Anicteric scleare. no conjunctival pallor. Patient refusing mouth examination. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. . >> DISCHARGE PHYSICAL EXAM: GEN: Patient repeats name, year, declines answering more questions. HEENT: Anicteric scleare. no conjunctival pallor. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. Pertinent Results: >> Pertinent Labs: ___ 11:03AM BLOOD WBC-7.0 RBC-3.56* Hgb-11.1* Hct-35.2 MCV-99* MCH-31.2 MCHC-31.5* RDW-13.5 RDWSD-48.6* Plt ___ ___ 11:03AM BLOOD Neuts-65.1 ___ Monos-12.0 Eos-0.9* Baso-0.6 Im ___ AbsNeut-4.57 AbsLymp-1.47 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.04 ___ 11:03AM BLOOD Glucose-101* UreaN-24* Creat-0.7 Na-145 K-3.6 Cl-107 HCO3-27 AnGap-15 ___ 11:03AM BLOOD VitB12-303 ___ 11:03AM BLOOD TSH-1.3 ___ 11:03AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . >> PERTINENT REPORTS: ___ Imaging CT HEAD W/O CONTRAST : There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. There is a mucus retention cyst in the left maxillary sinus with thickening of the lateral wall of the left maxilla suggesting chronic inflammation. The remaining imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. ___ Imaging MR HEAD W & W/O CONTRAS : Study is mildly degraded by motion. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is prominence of the ventricles and sulci suggestive involutional changes. Few subcortical T2 and FLAIR hyperintensities are noted. There is no abnormal enhancement after contrast administration. The major vascular flow voids are preserved. There is partial opacification of the mastoid air cells. Mucosal thickening with an air-fluid levels noted in the left maxillary sinus. Mild mucosal thickening of the ethmoid sinuses seen. There is a 0.9 cm Tornwaldt cyst versus mucous retention cyst in the posterior nasopharynx. The orbits and visualized soft tissues are otherwise normal. Nonspecific bilateral mastoid fluid is present. Degenerative changes are noted in the upper cervical spine. IMPRESSION: 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality. 3. Few scattered white matter signal abnormalities, likely secondary to chronic microvascular ischemic changes. 4. Air-fluid level in the left maxillary sinus, which may represent acute sinusitis. Brief Hospital Course: Ms. ___ is a ___ year old female, with past history of ? bipolar disorder / psychosis, now presenting with acute on chronic paranoia. . >> ACTIVE ISSUES: # Paranoia: Patient initially presented to ___ given increased paranoia and inability to care for herself. She was brought in by her husband, and history obtained by both patient and collateral from her husband. Patient had previously been diagnosed with a Bipolar disorder syndrome, and then patient moved to ___ ___ year ago. Over the past several months, patient had worsening paranoia and agitation, and therefore presented to ___. Patient had initial blood work which was unrevealing for an organic cause of her symptoms, and evaluated by psychiatry. Psychiatry felt that much of her symptoms were likely secondary to a depression with psychotic features type diagnosis instead of worsening of a prior diagnosis of Bipolar. Patient was initially started on treatment with Zyprexa 2.5 mg QHS, and Ativan given prior history of this. She was monitored serially, and underwent CT head and MRI imaging which was also negative for an acute organic cause of her symptoms. Therefore, patient was medically clear. Patient was started on empiric therapy for depression with mirtazapine, and was continued on standing anti-psychotic. Patient was also placed under ___ on ___ given inability to make full healthcare decisions. Patient was started on thiamine given nutritional needs. . # Elevated SBP: patient was noted to have an elevated SBP on admission, however this resolved during serial vital signs as an inpatient and therefore likely secondary to stress than true hypertension. . >> TRANSITIONAL ISSUES: # Paranoia: Patient to have f/u with geriatric psych unit. Patient may benefit from further behavioral stabilization, potentially ECT, and then will require further formal neurologic workup when behavirorally stable. # Discharge Psychiatric Regimen: Patient was started on mirtazapine 7.5 mg QHS, and also Zyprexa 2.5mg QHS. # Social Situation: Patient and her husband recently moved back from ___, likely need follow-up regarding resources. # CODE STATUS: Full # CONTACT: ___, Husband, ___ Medications on Admission: None Discharge Medications: 1. Mirtazapine 7.5 mg PO QHS 2. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS 3. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Paranoia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were hospitalized here because of an acute paranoia and change in mood, and we did blood tests and head imaging with a CT scan and an MRI which were negative. Therefore, we believe that you will benefit from psychiatric treatment. Please follow up with you physicians upon discharge from the hospital. Take Care, Your ___ Team. Followup Instructions: ___
[ "F23", "F1099", "F319", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Paranoia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. [MASKED] is a [MASKED] year old female, with prior history of Bipolar Disorder / Psychosis, now presenting with acute agitation. Patient with potentially prior late diagnosis of Bipolar Disorder / Psychosis? was previously living in [MASKED] for the past year, and returned to [MASKED] because of mental status changes. 6 weeks prior, Husband reports that she had become depressed secondary to potentially stress. She was also drinking alcohol, and she was being self-medicated with lorazepam and Haldol (which she had been previously described before). She now is a "basket case", and feels more paranoid and has potentially lost perception with reality. Patient thinks that everyone is against her. Her husband notes that she can be somewhat aggressive sometimes. She does endorse "emptiness" in her head, and her husband believes that she may have suffered several strokes in the past as well. She does not have any headaches, numbness/tingling, focal neurological deficits, or loss of function. Patient was first evaluated and found to have potentially an exacerbation of bipolar disorder vs. alcohol use vs. organic neurologic process. Patient was then evaluated to potentially need geriatric psych management. Past Psychiatry History: Reviewed in OMR. Patient was initially diagnosed with a bipolar disorder and had a psychotic break a few years ago. At that time, she was treated with Haldol and Ativan, and had somewhat improvement. Patient was then potentially tailored off medications, and then went into a "manic phase" that lasted ? "about a year". Patient was very energetic previously, and then mood stable. She was also drinking alcohol at that time. Last year, she and her husband then moved to [MASKED] for financial reasons and returned to the [MASKED] because of mental status changes. In the ED, initial vitals: 97.9 76 125/81 16 98% RA Labs were significant for: Sodium 145, Potassium 3.6, BUN 24, Cr 0.7. Serum Tox pending. TSH 1.3. Vitamin B12: Pending. Hgb 11.1. CT Head Imaging without contrast showed no acute intracranial abnormality. In the ED, she received: [MASKED] 12:27 PO Lorazepam 1 mg Vitals prior to transfer: UA 97.9 72 124/78 18 100% RA Currently, patient is standing in the room, refusing all care. Patient states that she would like to leave the hospital. Patient states that she feels that she is being kept here against her will. ROS: Unable to assess. Patient is not able to assess. Past Medical History: 1. Bipolar Disorder, Psychotic Break Social History: [MASKED] Family History: Declines answering questions. Physical Exam: >> ADMISSION PHYSICAL EXAM: GEN: Patient is refusing to acknowledge name, date of birth or place. She continues to state that she does not need to be here. Patient also continues to state that she would like to leave. HEENT: Anicteric scleare. no conjunctival pallor. Patient refusing mouth examination. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. . >> DISCHARGE PHYSICAL EXAM: GEN: Patient repeats name, year, declines answering more questions. HEENT: Anicteric scleare. no conjunctival pallor. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. Pertinent Results: >> Pertinent Labs: [MASKED] 11:03AM BLOOD WBC-7.0 RBC-3.56* Hgb-11.1* Hct-35.2 MCV-99* MCH-31.2 MCHC-31.5* RDW-13.5 RDWSD-48.6* Plt [MASKED] [MASKED] 11:03AM BLOOD Neuts-65.1 [MASKED] Monos-12.0 Eos-0.9* Baso-0.6 Im [MASKED] AbsNeut-4.57 AbsLymp-1.47 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.04 [MASKED] 11:03AM BLOOD Glucose-101* UreaN-24* Creat-0.7 Na-145 K-3.6 Cl-107 HCO3-27 AnGap-15 [MASKED] 11:03AM BLOOD VitB12-303 [MASKED] 11:03AM BLOOD TSH-1.3 [MASKED] 11:03AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . >> PERTINENT REPORTS: [MASKED] Imaging CT HEAD W/O CONTRAST : There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. There is a mucus retention cyst in the left maxillary sinus with thickening of the lateral wall of the left maxilla suggesting chronic inflammation. The remaining imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. [MASKED] Imaging MR HEAD W & W/O CONTRAS : Study is mildly degraded by motion. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is prominence of the ventricles and sulci suggestive involutional changes. Few subcortical T2 and FLAIR hyperintensities are noted. There is no abnormal enhancement after contrast administration. The major vascular flow voids are preserved. There is partial opacification of the mastoid air cells. Mucosal thickening with an air-fluid levels noted in the left maxillary sinus. Mild mucosal thickening of the ethmoid sinuses seen. There is a 0.9 cm Tornwaldt cyst versus mucous retention cyst in the posterior nasopharynx. The orbits and visualized soft tissues are otherwise normal. Nonspecific bilateral mastoid fluid is present. Degenerative changes are noted in the upper cervical spine. IMPRESSION: 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality. 3. Few scattered white matter signal abnormalities, likely secondary to chronic microvascular ischemic changes. 4. Air-fluid level in the left maxillary sinus, which may represent acute sinusitis. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female, with past history of ? bipolar disorder / psychosis, now presenting with acute on chronic paranoia. . >> ACTIVE ISSUES: # Paranoia: Patient initially presented to [MASKED] given increased paranoia and inability to care for herself. She was brought in by her husband, and history obtained by both patient and collateral from her husband. Patient had previously been diagnosed with a Bipolar disorder syndrome, and then patient moved to [MASKED] [MASKED] year ago. Over the past several months, patient had worsening paranoia and agitation, and therefore presented to [MASKED]. Patient had initial blood work which was unrevealing for an organic cause of her symptoms, and evaluated by psychiatry. Psychiatry felt that much of her symptoms were likely secondary to a depression with psychotic features type diagnosis instead of worsening of a prior diagnosis of Bipolar. Patient was initially started on treatment with Zyprexa 2.5 mg QHS, and Ativan given prior history of this. She was monitored serially, and underwent CT head and MRI imaging which was also negative for an acute organic cause of her symptoms. Therefore, patient was medically clear. Patient was started on empiric therapy for depression with mirtazapine, and was continued on standing anti-psychotic. Patient was also placed under [MASKED] on [MASKED] given inability to make full healthcare decisions. Patient was started on thiamine given nutritional needs. . # Elevated SBP: patient was noted to have an elevated SBP on admission, however this resolved during serial vital signs as an inpatient and therefore likely secondary to stress than true hypertension. . >> TRANSITIONAL ISSUES: # Paranoia: Patient to have f/u with geriatric psych unit. Patient may benefit from further behavioral stabilization, potentially ECT, and then will require further formal neurologic workup when behavirorally stable. # Discharge Psychiatric Regimen: Patient was started on mirtazapine 7.5 mg QHS, and also Zyprexa 2.5mg QHS. # Social Situation: Patient and her husband recently moved back from [MASKED], likely need follow-up regarding resources. # CODE STATUS: Full # CONTACT: [MASKED], Husband, [MASKED] Medications on Admission: None Discharge Medications: 1. Mirtazapine 7.5 mg PO QHS 2. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS 3. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Paranoia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you during your hospital stay at [MASKED]. You were hospitalized here because of an acute paranoia and change in mood, and we did blood tests and head imaging with a CT scan and an MRI which were negative. Therefore, we believe that you will benefit from psychiatric treatment. Please follow up with you physicians upon discharge from the hospital. Take Care, Your [MASKED] Team. Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "F23: Brief psychotic disorder", "F1099: Alcohol use, unspecified with unspecified alcohol-induced disorder", "F319: Bipolar disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,055,235
24,749,318
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: ___: Diagnostic cerebral angiogram History of Present Illness: ___ y/o male who presents as a transfer from ___ for evaluation of ICH and skull fracture s/p fall from standing while intoxicated. Pt arrives via ___ EMS. Per EMS, pt at home last night when he fell backwards and struck his head on the refrigerator at approx. 9pm, he was intoxicated at the time. EMS report unknown LOC, pt vomited after fall, went to bed. EMS states that pt presented to OSH after waking with worsening head/neck pain. Pt found to have R occipital skull fx with hemorrhage around spinal cord, he is transferred to ___ for further management. Pt awake and alert up on his arrival to the ED, with a GCS of 15. At the time of neurosurgical evaluation, patient endorses neck pain that had previously worsened with ROM, particularly looking to the right. He also endorses tingling in his hands, mainly his left fingers. No subjective weakness. No current HA, nausea or visual changes. Past Medical History: GERD Anxiety Social History: ___ Family History: NC Physical Exam: ON ADMISSION: ************ Physical Exam: O: T: 96.6 BP: 147/96 HR: 86 RR: 14 O2 Sat: 95% 2L NC GCS at the scene: 15 GCS upon Neurosurgery Evaluation: 15 Time of evaluation: 3pm Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: In hard C-collar. No acute distress. HEENT: PERRL 4-3mm, EOMs intact Extremities: Warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: PERRL 4-3mm. Visual fields are full to confrontation. III, IV, VI: EOMI 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. Handedness - Right Motor: D B T WE WF IP Q H AT ___ G Sensation: Intact to light touch Rectal exam deferred - no episodes incontinence ON DISCHARGE: ************* Exam: Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 6-4mm briskly reactive bilaterally EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right 5 5 5 5 5 Left 5 5 5 5 5 IPQuadHamATEHLGast Right5 5 5 5 5 5 Left5 5 5 5 5 5 [x]Sensation intact to light touch throughout all four extremities. *providing effort-dependent examination requiring repetitive prompting for full exertion of strength to reach ___. Pertinent Results: See OMR. Brief Hospital Course: ___ male admitted on ___ for injuries sustained during an intoxicated fall the evening of ___. Injuries included an acute SAH, cervical epidural hematoma, minimally displaced occipital condyle fracture and C1 transverse process fracture. He was admitted to Trauma overnight on ___ before being transferred to Neurosurgery on ___. #Subarachnoid hemorrhage c/b vasospasm CTA head/neck was performed for pattern of acute hemorrhage concerning for aneurysmal versus traumatic etiology, which was pertinent for attenuated basilar and left V4 as well as narrowing of right V4. He was taken for diagnostic cerebral angio on ___ that was negative for aneurysm or active bleeding, but pertinent for posterior circulation vasospasm. He was moved to the ___ for closer monitoring and started on Nimodipine, Keppra and IVF. On ___ overnight, the patient complained of blurry vision and ear pain. Stat CTA head with worsened vasospasm now in anterior circulation, transferred to ICU closer neurologic monitoring and pressors. TCDs on ___ showed severe vasospasm in the left MCA and moderate vasospasm in the vertebral arteries. He was given Toradol x3 for severe headaches with improvement. He was treated with pressors in ICU to maintain perfusion; pressors were weaned off during his ICU stay. He completed his 7 day course of Keppra and neuro checks were liberalized to q4 at night. CTA on ___ showed stable spasm. Dex was stopped on ___. CTA on ___ showed continued spasm, patient was kept in the ICU. The patient underwent TCDs on ___ which showed L MCA vasospasm. On ___ the patient had a CTA, continued to be in vasospasm. Kept euvolemic and clinically monitored closely. His exam has remained intact. #Occipital condyle fracture #C1 transverse process fracture Patient was put in a hard C-Collar for minimally displaced cervical fractures seen on CT C-Spine. MRI C-Spine redemonstrated findings from CT, but showed no evidence of ligamentous injury. #Pain APS was consulted on ___. Pain medications were adjusted per their recommendations with overall improvement in pain score. Pt continued to report pain, not well-tolerating and asking for opioid pain medication by name. Admitted to having history of opioid abuse. Addiction psych was consulted and made recommendations for weaning off sedating medications. #Cervical epidural hematoma A cervical epidural hematoma was noted on his initial CT C-Spine and was shown to be stable on repeat scan. #Alcohol withdrawal The patient was placed on CIWA scale and received diazepam for alcohol withdrawal. Addiction psych was consulted on ___. CIWA scale was discontinued on ___. #Left arm cellulitis/phlebitis Patient was started on a 10 day course of Bactrim for left arm cellulitis/phlebitis. WBC were uptrending Bactrim was switched to vanc. MRSA swab was sent on ___. Left arm US on ___ showed a small fluid collection, no occlusion. On ___, the Vancomycin was increased and he was started on a 14-day course of Ceftriaxone. His antibiotics were discontinued and he was started on Cefazolin on ___ which will be continued through ___. As patient prepared for discharge, IV abx were transitioned to PO Keflex on ___ to complete ___. #Dispo Social work, ___ and OT were consulted on ___ and initially recommended rehab, but as the patient progressed he no longer had rehab needs and recommendations were changed to discharge home. On the day of discharge, the patient expressed to staff that he was concerned about discharge; staff reviewed that he has been medically stable for >48hrs, reviewed follow up plan. Social work and case management met with patient to discuss safe discharge as well. Family updated on discharge plan. Pt expressing possible plan to fall on the way out of the hospital in order to remain inpatient; he was assisted to his transportation by nursing and security for safety. AHA/ASA Core Measures for ICH: 1. Dysphagia screening before any PO intake? [x]Yes []No 2. DVT prophylaxis administered? [x]Yes []No 3. Smoking cessation counseling given? [x]Yes []No [Reason: ()non-smoker ()unable to participate] 4. Stroke Education given in written form? [x]Yes []No 5. Assessment for rehabilitation and/or rehab services considered? [x]Yes []No Stroke Measures: 1. Was ___ performed within 6hrs of arrival? [x]Yes []No 2. Was a Procoagulant Reversal agent given? []Yes [x]No [Reason:no anticoagulation] 3. Was Nimodipine given? [x]Yes []No [Reason:] Medications on Admission: Klonopin 0.5mg TID Ranitidine 150mg QD Fluoxetine 40mg QD Fluticasone inhaler BID Gabapentin 800mg TID Nortriptyine 25mg QHS Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild Do not exceed greater than 4,000mg of tylenol in 24 hours RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tab-cap by mouth every six (6) hours Disp #*56 Tablet Refills:*0 2. Acetaminophen 325 mg PO Q6H Do not exceed greater than 4,000mg in 24 hours 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Please continue while taking narcotic pain meds. 4. Cephalexin 500 mg PO Q6H Duration: 8 Days End date ___ RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*32 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID Please continue while taking narcotic pain meds. 6. HYDROmorphone (Dilaudid) 2 mg PO TAPER PRN PAIN Pain - Moderate Duration: 7 Days Taper Instructions: RX *hydromorphone 2 mg Taper tablet(s) by mouth Taper PRN Pain Disp #*11 Tablet Refills:*0 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Nicotine Patch 14 mg/day TD DAILY RX *nicotine 14 mg/24 hour Apply 1 patch 24 hours Disp #*30 Patch Refills:*0 9. NiMODipine 60 mg PO Q4H Duration: 21 Days RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours Disp #*50 Capsule Refills:*0 10. Polyethylene Glycol 17 g PO DAILY Please continue while taking narcotic pain meds 11. Senna 8.6 mg PO BID Please continue while taking narcotic pain meds. 12. Sodium Chloride 1 gm PO TAPER Duration: 5 Days Please follow taper instructions: RX *sodium chloride 1 gram Taper tablet(s) by mouth Taper Disp #*8 Tablet Refills:*0 13. TraMADol 50 mg PO TAPER PRN Pain - Moderate Duration: 7 Days Please follow Taper Instructions RX *tramadol 50 mg Taper tablet(s) by mouth Taper prn pain Disp #*10 Tablet Refills:*0 14. Gabapentin 900 mg PO Q6H RX *gabapentin 300 mg 3 capsule(s) by mouth every six (6) hours Disp #*360 Capsule Refills:*0 15. ClonazePAM 0.5 mg PO Q8H 16. FLUoxetine 40 mg PO DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. Nortriptyline 25 mg PO QHS 19. Ranitidine 150 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage Cervical epidural hematoma Occipital condyle fracture C1 transverse process fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Traumatic Subarachnoid Hemorrhage Occipital Condyle Fracture Surgery/ Procedures: - You had a cerebral angiogram to evaluate for aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). - You have a fracture in your cervical spine. No surgery was performed on this fracture. It was treated with conservative management. You must wear your cervical collar at all times for 3 months until cleared to remove it by your neurosurgeon. 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. - You make take a shower. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you must refrain from driving. Medications - Resume your normal medications and begin new medications as directed. - Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. - You had a condition called hyponatremia (low blood sodium levels) while inpatient. You were started on salt tabs that are being tapered down slowly. You will taper off the salt tabs. Please take as directed per taper instructions below: SODIUM CHLORIDE (Salt tabs) TAPER INSTRUCTIONS: ** Prescription: 1mg tablets - Take 1g (1 tablet) every 12 hours x 4 doses (2 doses on ___, 2 doses on ___ - Take 1g (1 tablet) once a day x 2 doses (1 dose on ___, 1 dose on ___ - Off (___) You will need to follow up with your primary care provider ___ 1 week of discharge to monitor your blood sodium levels. A follow up appointment has been made for you on ___ at 11:30 AM with your primary care provider ___. It is very important you go to this appointment. Further appointment details listed below in follow up instructions. - You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). Your last day of this medication is on ___. - You are being discharged with specific instructions for narcotic pain medication taper. Please follow the taper instructions below. These medications may cause constipation. Please take over the counter stool softeners to prevent constipation while take narcotic pain meds. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. DO NOT DRIVE while taking narcotic pain medications. HYDROMORPHONE (DLAUDID) TAPER INSTRUCTIONS: **Prescription: 2mg tablets, PRN Pain - Take 2mg (1 tab) every Q8 hours x 4 doses (1 dose on ___, 3 doses on ___ - Take 2mg (1 tab) every 12 hours x 4 doses (2 doses on ___, 2 doses on ___ - Take 1mg ___ tab) every 12 hours x 4 doses (2 doses on ___, 2 doses on ___ - Take 1mg ___ tab) Once a day x 1 dose (1 dose on ___ - OFF ___ TRAMADOL TAPER INSTRUCTIONS: **Prescription: 50mg tablets, PRN pain - Take 50mg (1 tab) every 8 hours x 3 doses (___) - Take 50mg (1 tab) every 12 hours x 4 doses (2 doses on ___, 2 doses on ___ - Take 25mg ___ tab) every 12 hours x 4 doses (2 doses on ___, 2 doses on ___ - Take 25mg ___ tab) once a day x 2 doses (1 dose on ___, 1 dose on ___ - Off ___ - You were provided with a pain medication regimen that will require follow-up with outpatient Chronic Pain Services. For ongoing management and prescription refills please schedule an appointment at the ___ by calling ___. What You ___ Experience: - Mild to moderate headaches that last several days to a few weeks. - Difficulty with short term memory. - Fatigue is very normal - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: - Severe pain, swelling, redness or drainage from the incision site or puncture site. - Fever greater than 101.5 degrees Fahrenheit - Constipation - Blood in your stool or urine - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg 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: ___
[ "S066X9A", "S14101A", "S12091A", "F10239", "I67848", "R291", "E871", "L03114", "T82898A", "L02414", "T82594A", "S0211CA", "W01198A", "Y92010", "F17210", "K219", "R402413", "I959", "R739", "J45909", "E875", "Y710", "Y92230", "I493", "B9561", "D72829", "F418", "Y718" ]
Allergies: Penicillins Chief Complaint: Fall Major Surgical or Invasive Procedure: [MASKED]: Diagnostic cerebral angiogram History of Present Illness: [MASKED] y/o male who presents as a transfer from [MASKED] for evaluation of ICH and skull fracture s/p fall from standing while intoxicated. Pt arrives via [MASKED] EMS. Per EMS, pt at home last night when he fell backwards and struck his head on the refrigerator at approx. 9pm, he was intoxicated at the time. EMS report unknown LOC, pt vomited after fall, went to bed. EMS states that pt presented to OSH after waking with worsening head/neck pain. Pt found to have R occipital skull fx with hemorrhage around spinal cord, he is transferred to [MASKED] for further management. Pt awake and alert up on his arrival to the ED, with a GCS of 15. At the time of neurosurgical evaluation, patient endorses neck pain that had previously worsened with ROM, particularly looking to the right. He also endorses tingling in his hands, mainly his left fingers. No subjective weakness. No current HA, nausea or visual changes. Past Medical History: GERD Anxiety Social History: [MASKED] Family History: NC Physical Exam: ON ADMISSION: ************ Physical Exam: O: T: 96.6 BP: 147/96 HR: 86 RR: 14 O2 Sat: 95% 2L NC GCS at the scene: 15 GCS upon Neurosurgery Evaluation: 15 Time of evaluation: 3pm Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ [MASKED] Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: In hard C-collar. No acute distress. HEENT: PERRL 4-3mm, EOMs intact Extremities: Warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: PERRL 4-3mm. Visual fields are full to confrontation. III, IV, VI: EOMI 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. Handedness - Right Motor: D B T WE WF IP Q H AT [MASKED] G Sensation: Intact to light touch Rectal exam deferred - no episodes incontinence ON DISCHARGE: ************* Exam: Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 6-4mm briskly reactive bilaterally EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right 5 5 5 5 5 Left 5 5 5 5 5 IPQuadHamATEHLGast Right5 5 5 5 5 5 Left5 5 5 5 5 5 [x]Sensation intact to light touch throughout all four extremities. *providing effort-dependent examination requiring repetitive prompting for full exertion of strength to reach [MASKED]. Pertinent Results: See OMR. Brief Hospital Course: [MASKED] male admitted on [MASKED] for injuries sustained during an intoxicated fall the evening of [MASKED]. Injuries included an acute SAH, cervical epidural hematoma, minimally displaced occipital condyle fracture and C1 transverse process fracture. He was admitted to Trauma overnight on [MASKED] before being transferred to Neurosurgery on [MASKED]. #Subarachnoid hemorrhage c/b vasospasm CTA head/neck was performed for pattern of acute hemorrhage concerning for aneurysmal versus traumatic etiology, which was pertinent for attenuated basilar and left V4 as well as narrowing of right V4. He was taken for diagnostic cerebral angio on [MASKED] that was negative for aneurysm or active bleeding, but pertinent for posterior circulation vasospasm. He was moved to the [MASKED] for closer monitoring and started on Nimodipine, Keppra and IVF. On [MASKED] overnight, the patient complained of blurry vision and ear pain. Stat CTA head with worsened vasospasm now in anterior circulation, transferred to ICU closer neurologic monitoring and pressors. TCDs on [MASKED] showed severe vasospasm in the left MCA and moderate vasospasm in the vertebral arteries. He was given Toradol x3 for severe headaches with improvement. He was treated with pressors in ICU to maintain perfusion; pressors were weaned off during his ICU stay. He completed his 7 day course of Keppra and neuro checks were liberalized to q4 at night. CTA on [MASKED] showed stable spasm. Dex was stopped on [MASKED]. CTA on [MASKED] showed continued spasm, patient was kept in the ICU. The patient underwent TCDs on [MASKED] which showed L MCA vasospasm. On [MASKED] the patient had a CTA, continued to be in vasospasm. Kept euvolemic and clinically monitored closely. His exam has remained intact. #Occipital condyle fracture #C1 transverse process fracture Patient was put in a hard C-Collar for minimally displaced cervical fractures seen on CT C-Spine. MRI C-Spine redemonstrated findings from CT, but showed no evidence of ligamentous injury. #Pain APS was consulted on [MASKED]. Pain medications were adjusted per their recommendations with overall improvement in pain score. Pt continued to report pain, not well-tolerating and asking for opioid pain medication by name. Admitted to having history of opioid abuse. Addiction psych was consulted and made recommendations for weaning off sedating medications. #Cervical epidural hematoma A cervical epidural hematoma was noted on his initial CT C-Spine and was shown to be stable on repeat scan. #Alcohol withdrawal The patient was placed on CIWA scale and received diazepam for alcohol withdrawal. Addiction psych was consulted on [MASKED]. CIWA scale was discontinued on [MASKED]. #Left arm cellulitis/phlebitis Patient was started on a 10 day course of Bactrim for left arm cellulitis/phlebitis. WBC were uptrending Bactrim was switched to vanc. MRSA swab was sent on [MASKED]. Left arm US on [MASKED] showed a small fluid collection, no occlusion. On [MASKED], the Vancomycin was increased and he was started on a 14-day course of Ceftriaxone. His antibiotics were discontinued and he was started on Cefazolin on [MASKED] which will be continued through [MASKED]. As patient prepared for discharge, IV abx were transitioned to PO Keflex on [MASKED] to complete [MASKED]. #Dispo Social work, [MASKED] and OT were consulted on [MASKED] and initially recommended rehab, but as the patient progressed he no longer had rehab needs and recommendations were changed to discharge home. On the day of discharge, the patient expressed to staff that he was concerned about discharge; staff reviewed that he has been medically stable for >48hrs, reviewed follow up plan. Social work and case management met with patient to discuss safe discharge as well. Family updated on discharge plan. Pt expressing possible plan to fall on the way out of the hospital in order to remain inpatient; he was assisted to his transportation by nursing and security for safety. AHA/ASA Core Measures for ICH: 1. Dysphagia screening before any PO intake? [x]Yes []No 2. DVT prophylaxis administered? [x]Yes []No 3. Smoking cessation counseling given? [x]Yes []No [Reason: ()non-smoker ()unable to participate] 4. Stroke Education given in written form? [x]Yes []No 5. Assessment for rehabilitation and/or rehab services considered? [x]Yes []No Stroke Measures: 1. Was [MASKED] performed within 6hrs of arrival? [x]Yes []No 2. Was a Procoagulant Reversal agent given? []Yes [x]No [Reason:no anticoagulation] 3. Was Nimodipine given? [x]Yes []No [Reason:] Medications on Admission: Klonopin 0.5mg TID Ranitidine 150mg QD Fluoxetine 40mg QD Fluticasone inhaler BID Gabapentin 800mg TID Nortriptyine 25mg QHS Discharge Medications: 1. Acetaminophen-Caff-Butalbital [MASKED] TAB PO Q6H:PRN Pain - Mild Do not exceed greater than 4,000mg of tylenol in 24 hours RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [MASKED] tab-cap by mouth every six (6) hours Disp #*56 Tablet Refills:*0 2. Acetaminophen 325 mg PO Q6H Do not exceed greater than 4,000mg in 24 hours 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Please continue while taking narcotic pain meds. 4. Cephalexin 500 mg PO Q6H Duration: 8 Days End date [MASKED] RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*32 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID Please continue while taking narcotic pain meds. 6. HYDROmorphone (Dilaudid) 2 mg PO TAPER PRN PAIN Pain - Moderate Duration: 7 Days Taper Instructions: RX *hydromorphone 2 mg Taper tablet(s) by mouth Taper PRN Pain Disp #*11 Tablet Refills:*0 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Nicotine Patch 14 mg/day TD DAILY RX *nicotine 14 mg/24 hour Apply 1 patch 24 hours Disp #*30 Patch Refills:*0 9. NiMODipine 60 mg PO Q4H Duration: 21 Days RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours Disp #*50 Capsule Refills:*0 10. Polyethylene Glycol 17 g PO DAILY Please continue while taking narcotic pain meds 11. Senna 8.6 mg PO BID Please continue while taking narcotic pain meds. 12. Sodium Chloride 1 gm PO TAPER Duration: 5 Days Please follow taper instructions: RX *sodium chloride 1 gram Taper tablet(s) by mouth Taper Disp #*8 Tablet Refills:*0 13. TraMADol 50 mg PO TAPER PRN Pain - Moderate Duration: 7 Days Please follow Taper Instructions RX *tramadol 50 mg Taper tablet(s) by mouth Taper prn pain Disp #*10 Tablet Refills:*0 14. Gabapentin 900 mg PO Q6H RX *gabapentin 300 mg 3 capsule(s) by mouth every six (6) hours Disp #*360 Capsule Refills:*0 15. ClonazePAM 0.5 mg PO Q8H 16. FLUoxetine 40 mg PO DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. Nortriptyline 25 mg PO QHS 19. Ranitidine 150 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Subarachnoid hemorrhage Cervical epidural hematoma Occipital condyle fracture C1 transverse process fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Traumatic Subarachnoid Hemorrhage Occipital Condyle Fracture Surgery/ Procedures: - You had a cerebral angiogram to evaluate for aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). - You have a fracture in your cervical spine. No surgery was performed on this fracture. It was treated with conservative management. You must wear your cervical collar at all times for 3 months until cleared to remove it by your neurosurgeon. 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. - You make take a shower. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you must refrain from driving. Medications - Resume your normal medications and begin new medications as directed. - Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. - You had a condition called hyponatremia (low blood sodium levels) while inpatient. You were started on salt tabs that are being tapered down slowly. You will taper off the salt tabs. Please take as directed per taper instructions below: SODIUM CHLORIDE (Salt tabs) TAPER INSTRUCTIONS: ** Prescription: 1mg tablets - Take 1g (1 tablet) every 12 hours x 4 doses (2 doses on [MASKED], 2 doses on [MASKED] - Take 1g (1 tablet) once a day x 2 doses (1 dose on [MASKED], 1 dose on [MASKED] - Off ([MASKED]) You will need to follow up with your primary care provider [MASKED] 1 week of discharge to monitor your blood sodium levels. A follow up appointment has been made for you on [MASKED] at 11:30 AM with your primary care provider [MASKED]. It is very important you go to this appointment. Further appointment details listed below in follow up instructions. - You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). Your last day of this medication is on [MASKED]. - You are being discharged with specific instructions for narcotic pain medication taper. Please follow the taper instructions below. These medications may cause constipation. Please take over the counter stool softeners to prevent constipation while take narcotic pain meds. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. DO NOT DRIVE while taking narcotic pain medications. HYDROMORPHONE (DLAUDID) TAPER INSTRUCTIONS: **Prescription: 2mg tablets, PRN Pain - Take 2mg (1 tab) every Q8 hours x 4 doses (1 dose on [MASKED], 3 doses on [MASKED] - Take 2mg (1 tab) every 12 hours x 4 doses (2 doses on [MASKED], 2 doses on [MASKED] - Take 1mg [MASKED] tab) every 12 hours x 4 doses (2 doses on [MASKED], 2 doses on [MASKED] - Take 1mg [MASKED] tab) Once a day x 1 dose (1 dose on [MASKED] - OFF [MASKED] TRAMADOL TAPER INSTRUCTIONS: **Prescription: 50mg tablets, PRN pain - Take 50mg (1 tab) every 8 hours x 3 doses ([MASKED]) - Take 50mg (1 tab) every 12 hours x 4 doses (2 doses on [MASKED], 2 doses on [MASKED] - Take 25mg [MASKED] tab) every 12 hours x 4 doses (2 doses on [MASKED], 2 doses on [MASKED] - Take 25mg [MASKED] tab) once a day x 2 doses (1 dose on [MASKED], 1 dose on [MASKED] - Off [MASKED] - You were provided with a pain medication regimen that will require follow-up with outpatient Chronic Pain Services. For ongoing management and prescription refills please schedule an appointment at the [MASKED] by calling [MASKED]. What You [MASKED] Experience: - Mild to moderate headaches that last several days to a few weeks. - Difficulty with short term memory. - Fatigue is very normal - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at [MASKED] for: - Severe pain, swelling, redness or drainage from the incision site or puncture site. - Fever greater than 101.5 degrees Fahrenheit - Constipation - Blood in your stool or urine - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg 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]
[]
[ "E871", "F17210", "K219", "J45909", "Y92230" ]
[ "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S14101A: Unspecified injury at C1 level of cervical spinal cord, initial encounter", "S12091A: Other nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture", "F10239: Alcohol dependence with withdrawal, unspecified", "I67848: Other cerebrovascular vasospasm and vasoconstriction", "R291: Meningismus", "E871: Hypo-osmolality and hyponatremia", "L03114: Cellulitis of left upper limb", "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "L02414: Cutaneous abscess of left upper limb", "T82594A: Other mechanical complication of infusion catheter, initial encounter", "S0211CA: Type II occipital condyle fracture, right side, initial encounter for closed fracture", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Y92010: Kitchen of single-family (private) house as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "R402413: Glasgow coma scale score 13-15, at hospital admission", "I959: Hypotension, unspecified", "R739: Hyperglycemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "E875: Hyperkalemia", "Y710: Diagnostic and monitoring cardiovascular devices associated with adverse incidents", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I493: Ventricular premature depolarization", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "D72829: Elevated white blood cell count, unspecified", "F418: Other specified anxiety disorders", "Y718: Miscellaneous cardiovascular devices associated with adverse incidents, not elsewhere classified" ]
10,055,344
29,209,451
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Intubation Left heart cath Placement of IABP History of Present Illness: Mr ___ is a ___ year old ___ speaking male with a history of MI/3vCAD s/p multiple stents/PTCA in ___ who presents with SSCP, found to have acute LAD ___ thrombosis and resulting STEMI. Mr ___ was in his usual state of health until he began having chest discomfort at 0800 ___ AM. Initially ignored pain, but eventually developed into crushing SSCP. Called EMS who found him to have anterior STEMI. Given ASA in the field. Patient transferred directly to ___ cath lab by EMS. Angiography reviled an occluded proximal-LAD occlusion at the site of previous ___, concerning for ___ thrombosis. On the floor, the patient interviewed with assistance of his daughter. He denies chest pain, SOB, NVD, abdominal pain. He does report some suprapubic discomfort and persistent urge to void due to foley. Past Medical History: Diabetes (Diet Controlled) Hypertension Hyperlipidemia CAD s/p BMS to RCA x2 BMS to LAD and BMS to RI for IMI/3VD (___) with PTCA only of distal RCA (___) OA s/p TKR Gout Social History: ___ Family History: No family history of early heart disease Physical Exam: ADMISSION PHYSICAL EXAM: VS T 96.4, BP 126/45, HR 66, RR 25, O2 sat 100% GEN: In no acute distress, on IABP NECK: JVD could not be appreciated CV: RRR, nl S1 S2, no murmurs/rubs/gallops LUNGS: Clear anteriorly ABD: +BS, soft, non-tender, non-distended EXT: WWP, no edema NEURO: CN ___ grossly intact, moving all extremities spontaneously DISCHARGE PHYSICAL EXAM: CV: no heart sounds auscultated LUNGS: No lung sounds auscultated NEURO: fixed, dilated pupils Pertinent Results: ADMISSION LABS: ___ 06:30PM BLOOD WBC-7.6 RBC-3.72* Hgb-8.9* Hct-30.7* MCV-83 MCH-23.9* MCHC-29.0* RDW-16.1* RDWSD-48.3* Plt ___ ___ 06:30PM BLOOD ___ ___ 06:30PM BLOOD Glucose-203* UreaN-23* Creat-1.4* Na-140 K-3.9 Cl-105 HCO3-24 AnGap-15 ___ 06:30PM BLOOD ALT-53* CK(CPK)-2867* AlkPhos-90 ___ 03:50PM BLOOD cTropnT-<0.01 ___ 06:30PM BLOOD Albumin-3.5 ___ 06:30PM BLOOD %HbA1c-7.4* eAG-166* ___ 08:09AM BLOOD ___ pO2-66* pCO2-52* pH-7.13* calTCO2-18* Base XS--12 Comment-GREEN TOP ___ 08:09AM BLOOD Lactate-7.6* PERTINENT INTERVAL LABS: ___ 08:18PM BLOOD ALT-61* AST-430* LD(___)-498* CK(CPK)-5140* AlkPhos-96 ___ 04:08AM BLOOD CK(CPK)-4635* ___ 07:57AM BLOOD ALT-63* AST-375* LD(___)-1167* CK(CPK)-4153* AlkPhos-82 TotBili-0.7 ___ 11:13AM BLOOD ALT-66* AST-384* LD(___)-1330* AlkPhos-88 TotBili-0.7 ___ 02:49AM BLOOD ALT-809* AST-1223* CK(CPK)-3378* AlkPhos-81 TotBili-0.6 ___ 07:29AM BLOOD ALT-2435* AST-4570* LD(LDH)-6350* AlkPhos-71 TotBili-0.7 ___ 08:18PM BLOOD CK-MB-315* MB Indx-6.1* cTropnT-5.89* ___ 04:08AM BLOOD CK-MB-287* MB Indx-6.2* cTropnT-16.78* ___ 07:57AM BLOOD CK-MB-288* MB Indx-6.9* cTropnT-GREATER TH ___ 02:49AM BLOOD CK-MB-145* MB Indx-4.3 cTropnT-GREATER TH ___ 09:15AM BLOOD Type-ART pO2-257* pCO2-30* pH-7.28* calTCO2-15* Base XS--11 ___ 11:29AM BLOOD Type-ART pO2-164* pCO2-34* pH-7.28* calTCO2-17* Base XS--9 ___ 05:45PM BLOOD Type-ART pO2-206* pCO2-43 pH-7.22* calTCO2-19* Base XS--9 ___ 09:35PM BLOOD ___ Temp-37.4 pO2-242* pCO2-30* pH-7.24* calTCO2-13* Base XS--13 ___ 12:55AM BLOOD Type-MIX pH-7.12* ___ 03:07AM BLOOD Type-MIX pH-7.02* ___ 03:10AM BLOOD Type-ART pO2-102 pCO2-31* pH-7.07* calTCO2-10* Base XS--20 ___ 07:50AM BLOOD Type-MIX pH-7.15* ___ 10:49AM BLOOD Type-MIX ___ 11:39AM BLOOD Type-ART pO2-127* pCO2-20* pH-7.16* calTCO2-8* Base XS--19 DISCHARGE LABS: ___ 07:29AM BLOOD WBC-17.2* RBC-2.17* Hgb-5.3* Hct-18.6* MCV-86 MCH-24.4* MCHC-28.5* RDW-16.8* RDWSD-52.0* Plt ___ ___ 07:29AM BLOOD ___ PTT-59.0* ___ ___ 07:29AM BLOOD Glucose-319* UreaN-60* Creat-3.6* Na-144 K-4.6 Cl-98 HCO3-8* AnGap-43* ___ 07:29AM BLOOD ALT-2435* AST-4570* LD(LDH)-6350* AlkPhos-71 TotBili-0.7 ___ 07:29AM BLOOD Albumin-2.1* Calcium-7.5* Phos-9.5*# Mg-1.8 IMAGING/STUDIES: CATH REPORT ___ - three vessel CAD with very late ___ thrombosis of a prior proximal LAD cypher ___ with moderate ___ restenosis in the high OM! and chronic total occlusion of the RPDA. - severe LV diastolic heart failure - cardiogenic shock with systemic arterial hypotension requiring pressors and IABP insertion prior to PCI - successful deployment of 2 DES in the thrombotic proximal LAD - right femoral venous sheath secured in place for central IV access - left femoral arterial IABP secred in place (tip position confirmed on fluoroscopy relative to the calcified aortic knob) TTE ___ The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Hypokinesis of the basal and mid inferior and inferoseptal segmens is seen. Low-normal global left ventricular systolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Low-normal global systolic function in the setting of inferior/inferoseptal hypokinesis. Mild aortic and mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the inferoseptal wall motion abnormalities are new. The pulmonary artery systolic pressure is higher. CXR ___ In the interval, the patient has received a intra-aortic balloon pump. The tip of the pump projects approximately 1 cm be low the upper most portion of the aortic arch. No evidence of complications. No pneumothorax. No larger pleural effusions. KUB ___ No secondary signs of bowel ischemia (no gross pneumoperitoneum, pneumobilia, or dilated loops of bowel). CT A/P ___ -No acute findings in the abdomen or pelvis. No discrete findings to suggest bowel ischemia however a few small bowel loops are borderline in caliber and close clinical attention is advised as bowel distension can be the earliest finding of ischemia. -Intra-aortic balloon pump is demonstrated, which descends below and covers the origin of the celiac axis, SMA and bilateral renal arteries. -Diverticulosis without diverticulitis. -Single large gallstone. -Moderate dependent bilateral lower lobe atelectasis. -Fluid distention of the visualized portion of the esophagus. Surgical material is noted at the GE junction. CXR ___ the IABP has been advanced and is now beyond the transverse portion of the aortic arch approximately 1 cm, near the origin of the LSCA. MICROBIOLOGY: ___ UCx NG ___ BCx PENDING Brief Hospital Course: ___ year old ___ speaking male with a history of MI/3vCAD s/p multiple stents/PTCA who presents with SSCP, found to have acute LAD ___ thrombosis and resulting STEMI, s/p DES x2 to LAD, course complicated by hypotension requiring IABP, now with progressively worsening lactic acidosis on multiple pressors, ultimately expired from mixed cardiogenic and septic shock as well as progressive lactic acidosis. # SHOCK: The patient presented initially with cardiogenic shock in the setting of severe diastolic heart failure and recent STEMI. HE was treated with IABP and started on levophed for BP support. The patient was initially stabilized on this regimen, until he was found to have progressive lactic acidosis, requiring additional pressors and inotropes. The patient was initially treated with IVF boluses with improvement, until he became refractory to IVF and his lactic acid continued to rise. A swan-ganz catheter was placed in order to elucidate the underlying etiology of the patient's worsening hemodynamics. Worsened shock was thought to be mixed - cardiogenic due to heart failure as above as well as distributive shock due to possible bowel ischemia resulting in translocation of gut flora causing sepsis. The patient was started on broad spectrum antibiotics, increased levophed and dobutamine transitioned to vasopressin, as well as HCO3 bolus/gtt as needed. Though the patient had been evaluated with CT abdomen and pelvis which did not show any acute intra-abdominal pathology, mesenteric ischemia was suspected given his disproportionately elevated lactate. Mesenteric ischemia was thought to be secondary to low flow state in the setting of hypotension with possible underlying calcifications vs. embolism in the setting of cardiac cath or IABP placement. Though IABP was noted to be low, at the level of the mesenteric vessels, this was thought to be less likely the underlying etiology as flow would not be obstructed throughout the cardiac cycle. IABP was adjusted with no improvement. Bladder pressure was found to be normal making abdominal compartment syndrome less likely. Surgery was consulted, who did not believe patient was benefit from ex lap due to tenous hemodynamics. Nephrology was consulted, who did not believe the patient would benefit from CVVHD given tenous hemodynamics. The patient ultimately expired due to worsening lactic acidosis and mixed shock. # ANEMIA: The patient was found to have worsening H/H, thought to be secondary to hematemesis from ___ tear vs. dilutional in the setting of aggressive IVF resuscitation vs. other unknown etiology of blood loss. The patient's heparin was ultimately held as the risk of further bleeding was thought to outweigh the cardioprotective benefit. The patient was not transfused with pRBCs due to his expressly stated and documented religious beliefs. # ___ TEAR: The patient had an episode of hematemesis after vomiting in the cath lab and prior to presentation. The patient was initially treated with IV PPI and intubated for airway protection. GI was consulted, he was evaluated with EGD, found to have ___ which was closed endoscopically. Heparin was held for a period of time as the risks of further bleeding were thought to outweight the cardioprotective benefit. Heparin was restarted in discussion with GI and cardiology. # STEMI: Pt had a history of extensive CAD. He presented with acute onset chest pain, found to have very late ___ thrombosis of prior LAD ___. He was treated with 2 DES in proximal LAD. The patient was continued on ASA and started on ticagrelor which was ultimately held due to the bleeding concerns as above. The patient was continued on atorvastatin. The patient's troponin uptrended in the setting of worsening shock, thought to be due to demand ischemia due to severe hemodynamic compromise. # ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: (LVEF 55%) The patient has a history of severe diastolic heart failure with LVEF 55%. His shock, thought to be partially cardiogenic in origin due to his heart failure was managed as above. # TRANSAMINITIS: The patient was found to have worsening transaminitis, thought to be due to ischemia in the setting of shock as was as possible underlying component of congestion given his heart failure. # ACUTE KIDNEY INJURY/OLIGURIC RENAL FAILURE: The patient's Cr was elevated to 1.4 on admission from previous baseline 0.9-1.0. Cr gradually uptrended and urine output declined, thought to be due to ischemic insult in the setting of shock. # ANION GAP METABOLIC ACIDOSIS: secondary to lactic acidosis as above. The patient was treated with HCO3 bolus and gtt as above. CHRONIC ISSUES: # Diabetes (diet controlled): A1c 7.6% on admission. The patient was monitored on ISS. # Hypertension: home BP meds held given shock. # Hyperlipidemia: continued atorvastatin as above. # BPH: tamsulosin held in the setting of shock. Foley was placed and UOP was monitored. # Gout: continued allopurinol, held home colchicine TRANSITIONAL ISSUES: N/A patient expired Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB / Hypoxia 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Colchicine 0.6 mg PO DAILY:PRN Gout 5. Furosemide 40 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain 10. Tamsulosin 0.4 mg PO QHS 11. Acetaminophen 1000 mg PO Q8H:PRN Pain 12. Aspirin 81 mg PO DAILY 13. Artificial Tears ___ DROP BOTH EYES PRN Dry Eyes Discharge Medications: N/A patient expired Discharge Disposition: Expired Discharge Diagnosis: STEMI Cardiogenic shock Acute decompensated diastolic CHF Transaminitis / Shock Liver Sepsis Lactic Acidosis Diabetes Acute renal failure Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: ___
[ "I2109", "A419", "J9601", "K7200", "I5033", "N179", "R570", "R6521", "K226", "N183", "I237", "D62", "E872", "I471", "I25118", "I2582", "Z955", "I129", "Z87891", "Z531", "E119", "E785", "M1990", "Z96652" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Intubation Left heart cath Placement of IABP History of Present Illness: Mr [MASKED] is a [MASKED] year old [MASKED] speaking male with a history of MI/3vCAD s/p multiple stents/PTCA in [MASKED] who presents with SSCP, found to have acute LAD [MASKED] thrombosis and resulting STEMI. Mr [MASKED] was in his usual state of health until he began having chest discomfort at 0800 [MASKED] AM. Initially ignored pain, but eventually developed into crushing SSCP. Called EMS who found him to have anterior STEMI. Given ASA in the field. Patient transferred directly to [MASKED] cath lab by EMS. Angiography reviled an occluded proximal-LAD occlusion at the site of previous [MASKED], concerning for [MASKED] thrombosis. On the floor, the patient interviewed with assistance of his daughter. He denies chest pain, SOB, NVD, abdominal pain. He does report some suprapubic discomfort and persistent urge to void due to foley. Past Medical History: Diabetes (Diet Controlled) Hypertension Hyperlipidemia CAD s/p BMS to RCA x2 BMS to LAD and BMS to RI for IMI/3VD ([MASKED]) with PTCA only of distal RCA ([MASKED]) OA s/p TKR Gout Social History: [MASKED] Family History: No family history of early heart disease Physical Exam: ADMISSION PHYSICAL EXAM: VS T 96.4, BP 126/45, HR 66, RR 25, O2 sat 100% GEN: In no acute distress, on IABP NECK: JVD could not be appreciated CV: RRR, nl S1 S2, no murmurs/rubs/gallops LUNGS: Clear anteriorly ABD: +BS, soft, non-tender, non-distended EXT: WWP, no edema NEURO: CN [MASKED] grossly intact, moving all extremities spontaneously DISCHARGE PHYSICAL EXAM: CV: no heart sounds auscultated LUNGS: No lung sounds auscultated NEURO: fixed, dilated pupils Pertinent Results: ADMISSION LABS: [MASKED] 06:30PM BLOOD WBC-7.6 RBC-3.72* Hgb-8.9* Hct-30.7* MCV-83 MCH-23.9* MCHC-29.0* RDW-16.1* RDWSD-48.3* Plt [MASKED] [MASKED] 06:30PM BLOOD [MASKED] [MASKED] 06:30PM BLOOD Glucose-203* UreaN-23* Creat-1.4* Na-140 K-3.9 Cl-105 HCO3-24 AnGap-15 [MASKED] 06:30PM BLOOD ALT-53* CK(CPK)-2867* AlkPhos-90 [MASKED] 03:50PM BLOOD cTropnT-<0.01 [MASKED] 06:30PM BLOOD Albumin-3.5 [MASKED] 06:30PM BLOOD %HbA1c-7.4* eAG-166* [MASKED] 08:09AM BLOOD [MASKED] pO2-66* pCO2-52* pH-7.13* calTCO2-18* Base XS--12 Comment-GREEN TOP [MASKED] 08:09AM BLOOD Lactate-7.6* PERTINENT INTERVAL LABS: [MASKED] 08:18PM BLOOD ALT-61* AST-430* LD([MASKED])-498* CK(CPK)-5140* AlkPhos-96 [MASKED] 04:08AM BLOOD CK(CPK)-4635* [MASKED] 07:57AM BLOOD ALT-63* AST-375* LD([MASKED])-1167* CK(CPK)-4153* AlkPhos-82 TotBili-0.7 [MASKED] 11:13AM BLOOD ALT-66* AST-384* LD([MASKED])-1330* AlkPhos-88 TotBili-0.7 [MASKED] 02:49AM BLOOD ALT-809* AST-1223* CK(CPK)-3378* AlkPhos-81 TotBili-0.6 [MASKED] 07:29AM BLOOD ALT-2435* AST-4570* LD(LDH)-6350* AlkPhos-71 TotBili-0.7 [MASKED] 08:18PM BLOOD CK-MB-315* MB Indx-6.1* cTropnT-5.89* [MASKED] 04:08AM BLOOD CK-MB-287* MB Indx-6.2* cTropnT-16.78* [MASKED] 07:57AM BLOOD CK-MB-288* MB Indx-6.9* cTropnT-GREATER TH [MASKED] 02:49AM BLOOD CK-MB-145* MB Indx-4.3 cTropnT-GREATER TH [MASKED] 09:15AM BLOOD Type-ART pO2-257* pCO2-30* pH-7.28* calTCO2-15* Base XS--11 [MASKED] 11:29AM BLOOD Type-ART pO2-164* pCO2-34* pH-7.28* calTCO2-17* Base XS--9 [MASKED] 05:45PM BLOOD Type-ART pO2-206* pCO2-43 pH-7.22* calTCO2-19* Base XS--9 [MASKED] 09:35PM BLOOD [MASKED] Temp-37.4 pO2-242* pCO2-30* pH-7.24* calTCO2-13* Base XS--13 [MASKED] 12:55AM BLOOD Type-MIX pH-7.12* [MASKED] 03:07AM BLOOD Type-MIX pH-7.02* [MASKED] 03:10AM BLOOD Type-ART pO2-102 pCO2-31* pH-7.07* calTCO2-10* Base XS--20 [MASKED] 07:50AM BLOOD Type-MIX pH-7.15* [MASKED] 10:49AM BLOOD Type-MIX [MASKED] 11:39AM BLOOD Type-ART pO2-127* pCO2-20* pH-7.16* calTCO2-8* Base XS--19 DISCHARGE LABS: [MASKED] 07:29AM BLOOD WBC-17.2* RBC-2.17* Hgb-5.3* Hct-18.6* MCV-86 MCH-24.4* MCHC-28.5* RDW-16.8* RDWSD-52.0* Plt [MASKED] [MASKED] 07:29AM BLOOD [MASKED] PTT-59.0* [MASKED] [MASKED] 07:29AM BLOOD Glucose-319* UreaN-60* Creat-3.6* Na-144 K-4.6 Cl-98 HCO3-8* AnGap-43* [MASKED] 07:29AM BLOOD ALT-2435* AST-4570* LD(LDH)-6350* AlkPhos-71 TotBili-0.7 [MASKED] 07:29AM BLOOD Albumin-2.1* Calcium-7.5* Phos-9.5*# Mg-1.8 IMAGING/STUDIES: CATH REPORT [MASKED] - three vessel CAD with very late [MASKED] thrombosis of a prior proximal LAD cypher [MASKED] with moderate [MASKED] restenosis in the high OM! and chronic total occlusion of the RPDA. - severe LV diastolic heart failure - cardiogenic shock with systemic arterial hypotension requiring pressors and IABP insertion prior to PCI - successful deployment of 2 DES in the thrombotic proximal LAD - right femoral venous sheath secured in place for central IV access - left femoral arterial IABP secred in place (tip position confirmed on fluoroscopy relative to the calcified aortic knob) TTE [MASKED] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Hypokinesis of the basal and mid inferior and inferoseptal segmens is seen. Low-normal global left ventricular systolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Low-normal global systolic function in the setting of inferior/inferoseptal hypokinesis. Mild aortic and mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [MASKED], the inferoseptal wall motion abnormalities are new. The pulmonary artery systolic pressure is higher. CXR [MASKED] In the interval, the patient has received a intra-aortic balloon pump. The tip of the pump projects approximately 1 cm be low the upper most portion of the aortic arch. No evidence of complications. No pneumothorax. No larger pleural effusions. KUB [MASKED] No secondary signs of bowel ischemia (no gross pneumoperitoneum, pneumobilia, or dilated loops of bowel). CT A/P [MASKED] -No acute findings in the abdomen or pelvis. No discrete findings to suggest bowel ischemia however a few small bowel loops are borderline in caliber and close clinical attention is advised as bowel distension can be the earliest finding of ischemia. -Intra-aortic balloon pump is demonstrated, which descends below and covers the origin of the celiac axis, SMA and bilateral renal arteries. -Diverticulosis without diverticulitis. -Single large gallstone. -Moderate dependent bilateral lower lobe atelectasis. -Fluid distention of the visualized portion of the esophagus. Surgical material is noted at the GE junction. CXR [MASKED] the IABP has been advanced and is now beyond the transverse portion of the aortic arch approximately 1 cm, near the origin of the LSCA. MICROBIOLOGY: [MASKED] UCx NG [MASKED] BCx PENDING Brief Hospital Course: [MASKED] year old [MASKED] speaking male with a history of MI/3vCAD s/p multiple stents/PTCA who presents with SSCP, found to have acute LAD [MASKED] thrombosis and resulting STEMI, s/p DES x2 to LAD, course complicated by hypotension requiring IABP, now with progressively worsening lactic acidosis on multiple pressors, ultimately expired from mixed cardiogenic and septic shock as well as progressive lactic acidosis. # SHOCK: The patient presented initially with cardiogenic shock in the setting of severe diastolic heart failure and recent STEMI. HE was treated with IABP and started on levophed for BP support. The patient was initially stabilized on this regimen, until he was found to have progressive lactic acidosis, requiring additional pressors and inotropes. The patient was initially treated with IVF boluses with improvement, until he became refractory to IVF and his lactic acid continued to rise. A swan-ganz catheter was placed in order to elucidate the underlying etiology of the patient's worsening hemodynamics. Worsened shock was thought to be mixed - cardiogenic due to heart failure as above as well as distributive shock due to possible bowel ischemia resulting in translocation of gut flora causing sepsis. The patient was started on broad spectrum antibiotics, increased levophed and dobutamine transitioned to vasopressin, as well as HCO3 bolus/gtt as needed. Though the patient had been evaluated with CT abdomen and pelvis which did not show any acute intra-abdominal pathology, mesenteric ischemia was suspected given his disproportionately elevated lactate. Mesenteric ischemia was thought to be secondary to low flow state in the setting of hypotension with possible underlying calcifications vs. embolism in the setting of cardiac cath or IABP placement. Though IABP was noted to be low, at the level of the mesenteric vessels, this was thought to be less likely the underlying etiology as flow would not be obstructed throughout the cardiac cycle. IABP was adjusted with no improvement. Bladder pressure was found to be normal making abdominal compartment syndrome less likely. Surgery was consulted, who did not believe patient was benefit from ex lap due to tenous hemodynamics. Nephrology was consulted, who did not believe the patient would benefit from CVVHD given tenous hemodynamics. The patient ultimately expired due to worsening lactic acidosis and mixed shock. # ANEMIA: The patient was found to have worsening H/H, thought to be secondary to hematemesis from [MASKED] tear vs. dilutional in the setting of aggressive IVF resuscitation vs. other unknown etiology of blood loss. The patient's heparin was ultimately held as the risk of further bleeding was thought to outweigh the cardioprotective benefit. The patient was not transfused with pRBCs due to his expressly stated and documented religious beliefs. # [MASKED] TEAR: The patient had an episode of hematemesis after vomiting in the cath lab and prior to presentation. The patient was initially treated with IV PPI and intubated for airway protection. GI was consulted, he was evaluated with EGD, found to have [MASKED] which was closed endoscopically. Heparin was held for a period of time as the risks of further bleeding were thought to outweight the cardioprotective benefit. Heparin was restarted in discussion with GI and cardiology. # STEMI: Pt had a history of extensive CAD. He presented with acute onset chest pain, found to have very late [MASKED] thrombosis of prior LAD [MASKED]. He was treated with 2 DES in proximal LAD. The patient was continued on ASA and started on ticagrelor which was ultimately held due to the bleeding concerns as above. The patient was continued on atorvastatin. The patient's troponin uptrended in the setting of worsening shock, thought to be due to demand ischemia due to severe hemodynamic compromise. # ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: (LVEF 55%) The patient has a history of severe diastolic heart failure with LVEF 55%. His shock, thought to be partially cardiogenic in origin due to his heart failure was managed as above. # TRANSAMINITIS: The patient was found to have worsening transaminitis, thought to be due to ischemia in the setting of shock as was as possible underlying component of congestion given his heart failure. # ACUTE KIDNEY INJURY/OLIGURIC RENAL FAILURE: The patient's Cr was elevated to 1.4 on admission from previous baseline 0.9-1.0. Cr gradually uptrended and urine output declined, thought to be due to ischemic insult in the setting of shock. # ANION GAP METABOLIC ACIDOSIS: secondary to lactic acidosis as above. The patient was treated with HCO3 bolus and gtt as above. CHRONIC ISSUES: # Diabetes (diet controlled): A1c 7.6% on admission. The patient was monitored on ISS. # Hypertension: home BP meds held given shock. # Hyperlipidemia: continued atorvastatin as above. # BPH: tamsulosin held in the setting of shock. Foley was placed and UOP was monitored. # Gout: continued allopurinol, held home colchicine TRANSITIONAL ISSUES: N/A patient expired Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB / Hypoxia 2. Allopurinol [MASKED] mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Colchicine 0.6 mg PO DAILY:PRN Gout 5. Furosemide 40 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain 10. Tamsulosin 0.4 mg PO QHS 11. Acetaminophen 1000 mg PO Q8H:PRN Pain 12. Aspirin 81 mg PO DAILY 13. Artificial Tears [MASKED] DROP BOTH EYES PRN Dry Eyes Discharge Medications: N/A patient expired Discharge Disposition: Expired Discharge Diagnosis: STEMI Cardiogenic shock Acute decompensated diastolic CHF Transaminitis / Shock Liver Sepsis Lactic Acidosis Diabetes Acute renal failure Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: [MASKED]
[]
[ "J9601", "N179", "D62", "E872", "Z955", "I129", "Z87891", "E119", "E785" ]
[ "I2109: ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall", "A419: Sepsis, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "K7200: Acute and subacute hepatic failure without coma", "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "R570: Cardiogenic shock", "R6521: Severe sepsis with septic shock", "K226: Gastro-esophageal laceration-hemorrhage syndrome", "N183: Chronic kidney disease, stage 3 (moderate)", "I237: Postinfarction angina", "D62: Acute posthemorrhagic anemia", "E872: Acidosis", "I471: Supraventricular tachycardia", "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "I2582: Chronic total occlusion of coronary artery", "Z955: Presence of coronary angioplasty implant and graft", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z87891: Personal history of nicotine dependence", "Z531: Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z96652: Presence of left artificial knee joint" ]
10,055,595
29,749,985
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx of chronic pain, COPD not on O2, Type 2 DM, frequent UTI (ESBL E.coli), who presented to ___ hospital with 3 days of fatigue, nausea, vomiting and SOB. Patient reports that she has been feeling unwell for several days prior to admission. She barley ate anything at home and stayed in bed for nearly 2 days before eventually presenting to the hospital. Upon presentation to ___, patient was found to be hypoglycemic to 39 and hypotensive with SBP ___, with normal lactate. WBC 16.1, Cr 2.3, Ca ___. She was given 3L IVF and d50 with repeat finger sticks 156. She was started on Meropenum and transferred to ___ for further management. ___ was placed at ___. History was notable for several days of generalized malaise, mild lower abdominal discomfort and mild confusion, the later of which had improved by the time of transfer. In the ED, initial VS were: 97.5, 67, 123/72, 16, 100% Exam notable for: Labs showed: Lactate 1.1, CBC 10.1/14.2/44.7/152, Cr 1.3, UA pending Imaging showed: None done Received: Nothing Transfer VS were: 98.0, 78, 122/78, 18, 93% RA On arrival to the floor, patient reports that she is feeling much better and wishes she never presented to the ED in the first place because "now I'm stuck here for a few days." She denies current chest pain or SOB. Endorsed dysuria and foul smelling urine prior to admission. Denies fevers, chills. She lives at home with her boyfriend. Stopped smoking 4 days ago but endorses wheezing and cough. Does not use O2 at home. Uses marijuiana every night to help her sleep. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: History of frequent UTIs HPV Insulin-dependent type 2 diabetes. Chronic pain Right ankle pain s/p MVA in ___ and ORIF Facet arthropathy and degenerative disc disease (A lumbar CT on ___ showed diffuse disc bulges from L2-L5 causing mild spinal stenosis and osteophytic changes throughout the lumbar spine) Hyperparathyroidism Depression COPD Social History: ___ Family History: Non contribuatory Physical Exam: Admission ========= VS: 98.1, 118/62, 67 20 95 2l GENERAL: NAD, appears unkempt HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: diffuse end expiratory wheezes, rhonchi. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, moving all 4 extremities with purpose SKIN: lichenification with erythematous plaques on plantar suface of feet bilaterally, xerotic skin. Discharge ========= VS: 98.0 154 / 80 72 20 96 Ra GENERAL: NAD, pleasant, lying in bed. HEENT: AT/NC, EOMI, PERRL HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: diffuse end expiratory wheezes, rhonchi. ABDOMEN: ND/NT. No rebound or guarding EXTREMITIES: WWP. No edema. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, moving all 4 extremities with purpose SKIN: lichenification with erythematous plaques on plantar suface of feet bilaterally, xerotic skin. Pertinent Results: Admission labs ============== ___ 11:50PM BLOOD WBC-10.1* RBC-4.54 Hgb-14.2 Hct-44.7 MCV-99* MCH-31.3 MCHC-31.8* RDW-13.6 RDWSD-49.8* Plt ___ ___ 11:50PM BLOOD Plt ___ ___ 11:50PM BLOOD Glucose-160* UreaN-37* Creat-1.3* Na-135 K-4.7 Cl-106 HCO3-23 AnGap-11 ___ 11:50PM BLOOD Calcium-10.0 Phos-3.3 Mg-1.6 ___ 08:00AM BLOOD PTH-127* Discharge Labs ============== ___ 08:25AM BLOOD WBC-8.4 RBC-4.82 Hgb-15.0 Hct-47.7* MCV-99* MCH-31.1 MCHC-31.4* RDW-13.7 RDWSD-50.0* Plt ___ ___ 08:25AM BLOOD Plt ___ ___ 08:25AM BLOOD Glucose-206* UreaN-25* Creat-0.7 Na-141 K-5.3* Cl-105 HCO3-30 AnGap-11 ___ 08:25AM BLOOD Calcium-10.7* Phos-2.2* Mg-1.7 Imaging & Studies ================== none Microbiology ============ ___ 12:50 am URINE Site: CLEAN CATCH **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Brief Hospital Course: ___ with PMHx of chronic pain, Type 2 DM, frequent UTI (ESBL E.coli), who presented to ___ with 3 days of fatigue, nausea, vomiting and SOB, found to be hypoglycemia and hypotensive with positive UA presumed to be due to ESBL E. Coli UTI from ___ UCx at ___. Patient was treated with meropenem and then transitioned to fosfomycin per recommendations of infectious disease. Patient's condition rapidly improved and she will be continued on fosfomycin for a total treatment course to end on ___ to complete 3 dose course. Patient had hypoglycemia at presentation due to poor PO intake and this resolved shortly after admission. Her potassium was elevated to 5.3 on the day of discharge and she will need repeat labs in ___ days and follow up with her PCP. ==================== ACUTE MEDICAL ISSUES ==================== # Sepsis secondary to ESBL UTI UA on presentation grossly positive, in setting of symptoms of malaise, nausea, and associated hypotension with leukocytosis likely to represent urosepsis. Patient was responsive to fluids. She was treated with meropenem for presumed ESBL UTI. This was switched to fosfomycin on ___ for three dose regimen to treat complicated UTI. Labs returned to baseline and patient felt well beyond baseline incontinence. She will be continued on fosfomycin for treatment course to end on ___. Abx: meropenem [___] fosfomycin 3g q48h for 3 doses [___] # Hypoglycemia. # IDDM. Last A1c 8.4 Blood glucose on presentation to OSH 39 with associated nausea, confusion likely reflecting symptomatic hypoglycemia. Etiology likely be in setting of decreased PO intake without adjustment in home insulin dose. Stabilized on dose-reduced regimen. Will be discharged on home regimen now that has resolved and PO intake improved. # Hyperparathyroidism. (___ 160-170 per ___ records since ___ # Hypercalcemic. Ca ___ at ___ prior to transfer, near outpatient baseline ___ since ___. Likely ___ hyperparathyroidism given elevated PTH 160-170s and normal renal function. Improved with treatment with IVF. PTH during this admission was 127. She will need evaluation as an outpatient for consideration of surgical treatment. # Hyperphosphatemia: K elevated to 5.3. Likely in the setting of mild hyperglycemia and may represent normal level. Will need repeat level on ___ to assess for resolution. # ___. Creatinine peaked at 2.3 on admission to OSH, above baseline normal 0.7-0.9 value as outpatient. Resolved to baseline with fluids. # COPD. Not on home O2. Current every day smoker. Was continued on duonebs and albuterol. She will resume home meds post-discharge. # Chronic pain. ___ DJD, facet arthropathy past, spinal stenosis and past ankle injury. Followed by Comprehensive Pain Center at ___. Continued on home regimen of MS ___ 15 mg TID, Vicodin ___ mg BID prn, and gabapentin 800mg TID. # Anxiety/Depression Continued on fluoxetine 80mg daily # Incontinence. Patient with reported overactive bladder followed by urology. She was continued on oxybutynin. She will need follow up with urology as outpatient for continued symptoms and risk of UTI. # HTN Enalapril held on discharge due to hyperkalemia # Allergies Continued on loratadine 10mg daily # HLD: Continued on simvastatin 20mg QHS # Restless leg syndrome Held ropinorole. Can resume after discharge at home dose. ====================== TRANSITIONAL ISSUES ====================== - Patient was discharged on fosfomycin to complete an ___g q48h to end on ___. - Final urine culture sensitivities showed mixed flora with repeat urine culture at ___ negative. Urine culture from ___ at ___ showed ESBL, presumed sensitive to fosfomycin. - Developed hyperkalemia to 5.3. She will need repeat Chem 7 on ___ to assess for resolution. - Enalapril was held at time of discharge due to hyperkalemia. Can be restarted by PCP as outpatient. - Consider referral to urology for incontinence. - Consider referral for treatment of hyperparathyroidism # Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS ___ 15 mg PO Q8H 2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q12H:PRN Pain - Severe 3. Gabapentin 800 mg PO TID 4. FLUoxetine 80 mg PO DAILY 5. Glargine 50 Units Bedtime NOVOLOG 12 Units Breakfast NOVOLOG 12 Units Lunch NOVOLOG 12 Units Dinner Insulin SC Sliding Scale using NOVOLOG Insulin 6. Oxybutynin 5 mg PO TID 7. Loratadine 10 mg PO DAILY 8. Linzess (linaclotide) 145 mcg oral DAILY 9. rOPINIRole 1 mg PO BID 10. rOPINIRole 2 mg PO QHS 11. Enalapril Maleate 5 mg PO DAILY 12. Ranitidine 150 mg PO BID 13. Omeprazole 20 mg PO BID 14. FoLIC Acid 1 mg PO DAILY 15. Simvastatin 20 mg PO QPM 16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 17. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Fosfomycin Tromethamine 3 g PO Q48H Duration: 3 Doses RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth Q48H Disp #*2 Packet Refills:*0 2. Glargine 50 Units Bedtime NOVOLOG 12 Units Breakfast NOVOLOG 12 Units Lunch NOVOLOG 12 Units Dinner Insulin SC Sliding Scale using NOVOLOG Insulin 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 4. FLUoxetine 80 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q12H:PRN Pain - Severe 8. Linzess (linaclotide) 145 mcg oral DAILY 9. Loratadine 10 mg PO DAILY 10. Morphine SR (MS ___ 15 mg PO Q8H 11. Omeprazole 20 mg PO BID 12. Oxybutynin 5 mg PO TID 13. Ranitidine 150 mg PO BID 14. rOPINIRole 1 mg PO BID 15. rOPINIRole 2 mg PO QHS 16. Simvastatin 20 mg PO QPM 17. Tiotropium Bromide 1 CAP IH DAILY 18. HELD- Enalapril Maleate 5 mg PO DAILY This medication was held. Do not restart Enalapril Maleate until you talk to your doctor 19.Outpatient Lab Work ICD-10 Hyperkalemia E87.5 Please draw Chem 7 Fax results to: ___ attn: ___, M.D Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary diagnosis - sepsis secondary to urinary tract infection, with previous history of ESBL Secondary diagnoses - insulin dependent diabetes - hyperparathyroidism - acute kidney injury secondary to hypovolemia - COPD - depression/anxiety - chronic pain - hypertension - hyperlipidemia - Restless leg 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 to be a part of your care team at ___ ___. You were admitted to the hospital because of a serious urinary tract infection. You were given antibiotics, and you started to feel better. When you leave the hospital you should continue to take an antibiotic called fosfomycin. You will need to take 2 more doses of this medication. You should take one dose of this medication on ___ and another dose of the medication on ___. Please do not take your enalapril until you meet with your doctor. Your potassium levels were slightly elevated to 5.3. You should have repeat labs drawn on ___ and meet with you primary doctor on ___ for an appointment. It was a privilege taking care of you and we wish you the best. Sincerely, Your ___ Team Followup Instructions: ___
[ "A4151", "N179", "I959", "E1165", "N390", "B9629", "E213", "E861", "J449", "F329", "F419", "I10", "E785", "G2581", "Z794", "M5136", "M4806", "F17210", "G4700", "F1290", "M1990", "M25571", "G8929", "S99911S", "V892XXS", "T7840XA", "Z1624" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMHx of chronic pain, COPD not on O2, Type 2 DM, frequent UTI (ESBL E.coli), who presented to [MASKED] hospital with 3 days of fatigue, nausea, vomiting and SOB. Patient reports that she has been feeling unwell for several days prior to admission. She barley ate anything at home and stayed in bed for nearly 2 days before eventually presenting to the hospital. Upon presentation to [MASKED], patient was found to be hypoglycemic to 39 and hypotensive with SBP [MASKED], with normal lactate. WBC 16.1, Cr 2.3, Ca [MASKED]. She was given 3L IVF and d50 with repeat finger sticks 156. She was started on Meropenum and transferred to [MASKED] for further management. [MASKED] was placed at [MASKED]. History was notable for several days of generalized malaise, mild lower abdominal discomfort and mild confusion, the later of which had improved by the time of transfer. In the ED, initial VS were: 97.5, 67, 123/72, 16, 100% Exam notable for: Labs showed: Lactate 1.1, CBC 10.1/14.2/44.7/152, Cr 1.3, UA pending Imaging showed: None done Received: Nothing Transfer VS were: 98.0, 78, 122/78, 18, 93% RA On arrival to the floor, patient reports that she is feeling much better and wishes she never presented to the ED in the first place because "now I'm stuck here for a few days." She denies current chest pain or SOB. Endorsed dysuria and foul smelling urine prior to admission. Denies fevers, chills. She lives at home with her boyfriend. Stopped smoking 4 days ago but endorses wheezing and cough. Does not use O2 at home. Uses marijuiana every night to help her sleep. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: History of frequent UTIs HPV Insulin-dependent type 2 diabetes. Chronic pain Right ankle pain s/p MVA in [MASKED] and ORIF Facet arthropathy and degenerative disc disease (A lumbar CT on [MASKED] showed diffuse disc bulges from L2-L5 causing mild spinal stenosis and osteophytic changes throughout the lumbar spine) Hyperparathyroidism Depression COPD Social History: [MASKED] Family History: Non contribuatory Physical Exam: Admission ========= VS: 98.1, 118/62, 67 20 95 2l GENERAL: NAD, appears unkempt HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: diffuse end expiratory wheezes, rhonchi. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, moving all 4 extremities with purpose SKIN: lichenification with erythematous plaques on plantar suface of feet bilaterally, xerotic skin. Discharge ========= VS: 98.0 154 / 80 72 20 96 Ra GENERAL: NAD, pleasant, lying in bed. HEENT: AT/NC, EOMI, PERRL HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: diffuse end expiratory wheezes, rhonchi. ABDOMEN: ND/NT. No rebound or guarding EXTREMITIES: WWP. No edema. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, moving all 4 extremities with purpose SKIN: lichenification with erythematous plaques on plantar suface of feet bilaterally, xerotic skin. Pertinent Results: Admission labs ============== [MASKED] 11:50PM BLOOD WBC-10.1* RBC-4.54 Hgb-14.2 Hct-44.7 MCV-99* MCH-31.3 MCHC-31.8* RDW-13.6 RDWSD-49.8* Plt [MASKED] [MASKED] 11:50PM BLOOD Plt [MASKED] [MASKED] 11:50PM BLOOD Glucose-160* UreaN-37* Creat-1.3* Na-135 K-4.7 Cl-106 HCO3-23 AnGap-11 [MASKED] 11:50PM BLOOD Calcium-10.0 Phos-3.3 Mg-1.6 [MASKED] 08:00AM BLOOD PTH-127* Discharge Labs ============== [MASKED] 08:25AM BLOOD WBC-8.4 RBC-4.82 Hgb-15.0 Hct-47.7* MCV-99* MCH-31.1 MCHC-31.4* RDW-13.7 RDWSD-50.0* Plt [MASKED] [MASKED] 08:25AM BLOOD Plt [MASKED] [MASKED] 08:25AM BLOOD Glucose-206* UreaN-25* Creat-0.7 Na-141 K-5.3* Cl-105 HCO3-30 AnGap-11 [MASKED] 08:25AM BLOOD Calcium-10.7* Phos-2.2* Mg-1.7 Imaging & Studies ================== none Microbiology ============ [MASKED] 12:50 am URINE Site: CLEAN CATCH **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. Brief Hospital Course: [MASKED] with PMHx of chronic pain, Type 2 DM, frequent UTI (ESBL E.coli), who presented to [MASKED] with 3 days of fatigue, nausea, vomiting and SOB, found to be hypoglycemia and hypotensive with positive UA presumed to be due to ESBL E. Coli UTI from [MASKED] UCx at [MASKED]. Patient was treated with meropenem and then transitioned to fosfomycin per recommendations of infectious disease. Patient's condition rapidly improved and she will be continued on fosfomycin for a total treatment course to end on [MASKED] to complete 3 dose course. Patient had hypoglycemia at presentation due to poor PO intake and this resolved shortly after admission. Her potassium was elevated to 5.3 on the day of discharge and she will need repeat labs in [MASKED] days and follow up with her PCP. ==================== ACUTE MEDICAL ISSUES ==================== # Sepsis secondary to ESBL UTI UA on presentation grossly positive, in setting of symptoms of malaise, nausea, and associated hypotension with leukocytosis likely to represent urosepsis. Patient was responsive to fluids. She was treated with meropenem for presumed ESBL UTI. This was switched to fosfomycin on [MASKED] for three dose regimen to treat complicated UTI. Labs returned to baseline and patient felt well beyond baseline incontinence. She will be continued on fosfomycin for treatment course to end on [MASKED]. Abx: meropenem [[MASKED]] fosfomycin 3g q48h for 3 doses [[MASKED]] # Hypoglycemia. # IDDM. Last A1c 8.4 Blood glucose on presentation to OSH 39 with associated nausea, confusion likely reflecting symptomatic hypoglycemia. Etiology likely be in setting of decreased PO intake without adjustment in home insulin dose. Stabilized on dose-reduced regimen. Will be discharged on home regimen now that has resolved and PO intake improved. # Hyperparathyroidism. ([MASKED] 160-170 per [MASKED] records since [MASKED] # Hypercalcemic. Ca [MASKED] at [MASKED] prior to transfer, near outpatient baseline [MASKED] since [MASKED]. Likely [MASKED] hyperparathyroidism given elevated PTH 160-170s and normal renal function. Improved with treatment with IVF. PTH during this admission was 127. She will need evaluation as an outpatient for consideration of surgical treatment. # Hyperphosphatemia: K elevated to 5.3. Likely in the setting of mild hyperglycemia and may represent normal level. Will need repeat level on [MASKED] to assess for resolution. # [MASKED]. Creatinine peaked at 2.3 on admission to OSH, above baseline normal 0.7-0.9 value as outpatient. Resolved to baseline with fluids. # COPD. Not on home O2. Current every day smoker. Was continued on duonebs and albuterol. She will resume home meds post-discharge. # Chronic pain. [MASKED] DJD, facet arthropathy past, spinal stenosis and past ankle injury. Followed by Comprehensive Pain Center at [MASKED]. Continued on home regimen of MS [MASKED] 15 mg TID, Vicodin [MASKED] mg BID prn, and gabapentin 800mg TID. # Anxiety/Depression Continued on fluoxetine 80mg daily # Incontinence. Patient with reported overactive bladder followed by urology. She was continued on oxybutynin. She will need follow up with urology as outpatient for continued symptoms and risk of UTI. # HTN Enalapril held on discharge due to hyperkalemia # Allergies Continued on loratadine 10mg daily # HLD: Continued on simvastatin 20mg QHS # Restless leg syndrome Held ropinorole. Can resume after discharge at home dose. ====================== TRANSITIONAL ISSUES ====================== - Patient was discharged on fosfomycin to complete an g q48h to end on [MASKED]. - Final urine culture sensitivities showed mixed flora with repeat urine culture at [MASKED] negative. Urine culture from [MASKED] at [MASKED] showed ESBL, presumed sensitive to fosfomycin. - Developed hyperkalemia to 5.3. She will need repeat Chem 7 on [MASKED] to assess for resolution. - Enalapril was held at time of discharge due to hyperkalemia. Can be restarted by PCP as outpatient. - Consider referral to urology for incontinence. - Consider referral for treatment of hyperparathyroidism # Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS [MASKED] 15 mg PO Q8H 2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q12H:PRN Pain - Severe 3. Gabapentin 800 mg PO TID 4. FLUoxetine 80 mg PO DAILY 5. Glargine 50 Units Bedtime NOVOLOG 12 Units Breakfast NOVOLOG 12 Units Lunch NOVOLOG 12 Units Dinner Insulin SC Sliding Scale using NOVOLOG Insulin 6. Oxybutynin 5 mg PO TID 7. Loratadine 10 mg PO DAILY 8. Linzess (linaclotide) 145 mcg oral DAILY 9. rOPINIRole 1 mg PO BID 10. rOPINIRole 2 mg PO QHS 11. Enalapril Maleate 5 mg PO DAILY 12. Ranitidine 150 mg PO BID 13. Omeprazole 20 mg PO BID 14. FoLIC Acid 1 mg PO DAILY 15. Simvastatin 20 mg PO QPM 16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 17. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Fosfomycin Tromethamine 3 g PO Q48H Duration: 3 Doses RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth Q48H Disp #*2 Packet Refills:*0 2. Glargine 50 Units Bedtime NOVOLOG 12 Units Breakfast NOVOLOG 12 Units Lunch NOVOLOG 12 Units Dinner Insulin SC Sliding Scale using NOVOLOG Insulin 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 4. FLUoxetine 80 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q12H:PRN Pain - Severe 8. Linzess (linaclotide) 145 mcg oral DAILY 9. Loratadine 10 mg PO DAILY 10. Morphine SR (MS [MASKED] 15 mg PO Q8H 11. Omeprazole 20 mg PO BID 12. Oxybutynin 5 mg PO TID 13. Ranitidine 150 mg PO BID 14. rOPINIRole 1 mg PO BID 15. rOPINIRole 2 mg PO QHS 16. Simvastatin 20 mg PO QPM 17. Tiotropium Bromide 1 CAP IH DAILY 18. HELD- Enalapril Maleate 5 mg PO DAILY This medication was held. Do not restart Enalapril Maleate until you talk to your doctor 19.Outpatient Lab Work ICD-10 Hyperkalemia E87.5 Please draw Chem 7 Fax results to: [MASKED] attn: [MASKED], M.D Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Primary diagnosis - sepsis secondary to urinary tract infection, with previous history of ESBL Secondary diagnoses - insulin dependent diabetes - hyperparathyroidism - acute kidney injury secondary to hypovolemia - COPD - depression/anxiety - chronic pain - hypertension - hyperlipidemia - Restless leg 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 to be a part of your care team at [MASKED] [MASKED]. You were admitted to the hospital because of a serious urinary tract infection. You were given antibiotics, and you started to feel better. When you leave the hospital you should continue to take an antibiotic called fosfomycin. You will need to take 2 more doses of this medication. You should take one dose of this medication on [MASKED] and another dose of the medication on [MASKED]. Please do not take your enalapril until you meet with your doctor. Your potassium levels were slightly elevated to 5.3. You should have repeat labs drawn on [MASKED] and meet with you primary doctor on [MASKED] for an appointment. It was a privilege taking care of you and we wish you the best. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "E1165", "N390", "J449", "F329", "F419", "I10", "E785", "Z794", "F17210", "G4700", "G8929" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "N179: Acute kidney failure, unspecified", "I959: Hypotension, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N390: Urinary tract infection, site not specified", "B9629: Other Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E213: Hyperparathyroidism, unspecified", "E861: Hypovolemia", "J449: Chronic obstructive pulmonary disease, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G2581: Restless legs syndrome", "Z794: Long term (current) use of insulin", "M5136: Other intervertebral disc degeneration, lumbar region", "M4806: Spinal stenosis, lumbar region", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G4700: Insomnia, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "M1990: Unspecified osteoarthritis, unspecified site", "M25571: Pain in right ankle and joints of right foot", "G8929: Other chronic pain", "S99911S: Unspecified injury of right ankle, sequela", "V892XXS: Person injured in unspecified motor-vehicle accident, traffic, sequela", "T7840XA: Allergy, unspecified, initial encounter", "Z1624: Resistance to multiple antibiotics" ]
10,055,694
21,758,998
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___. Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: ___ Upper GI endoscopy History of Present Illness: Ms. ___ is a ___ y/o woman with past history of ESRD s/p transplant on HD (___), COPD, GERD (w/out PUD), atrial fibrillation not on coumadin, recurrent cdiff infection presents with hypotension and worsening anemia in setting of melena. Patient reports dark, painless stools for approximately one week. Underwent HD on morning of admission and was noted to have Hb 7.8 (down from baseline ___ and hypotensive to SBP 70-80's. Baseline SBP in 90's post dialysis. She denies fevers, chills, chest pain, sob, abdominal pain, nausea, vomiting, dysuria, frequency, diarrhea. Of note, patient previously trialed on anticoagulation for atrial fibrillation, but experienced massive GIB without source being identified (underwent endoscopy, capsule). In the ED, initial vitals: T 98.0, P 95, BP 82/41 RR 16 O2 99% RA - Exam notable for rectal exam with melena. - Labs were notable for: Hb 7.4 (b/l ___, lactate 1.3. trop<0.01, phos 2.3. Remainder electrolytes wnl. Serum tox negative. - Imaging: CXR showed moderate pulmonary edema. - Patient was given: IV Pantoprazole 80mg IV, 1u PRBC's - Consults: GI Admitted to MICU given hypotension and multiple comorbidities. On arrival to the MICU, she reports feeling well and at her baseline. She says she would otherwise be driving to the store to grocery shop. She does note some dark brown stools but denies seeing frank black stools. She denies dizziness, lightheadedness, chest pain, or SOB that is worse than baseline. She wear 2L of home O2. She has not had any medication changes preceding this admission. She denies confusion at home, falls, or vomiting. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant in - FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in ___ and treated with flagyl 500mg x 10 days; again in ___ s/p flagyl 500mg x 14 days, persistent infection still later in ___, treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother on dialysis from DM. Niece with ESRD, s/p transplant Physical Exam: >> ADMISSION EXAM: Vitals: 92/56 HR79 O2 98% on 2L HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: mild inspiratory and expiratory wheezes throughout. CV: Irregularly irregular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Distended, TTP throughout ___ her stomach. bowel sounds present, Enlarged liver. EXT: Warm, well perfused, 2+ pulses, trace ___. NEURO: CN II-XII grossly intact, moving all extremities appropriately. No asterxsis. ACCESS: LUE fistula, 2 PIVs. . >> DISCHARGE EXAM: Vitals: T 98.4, HR 81, BP 100-113/55-57, RR 18, SpO2 100% on 3L NC General: Sitting up in bed, moving about room. HEENT: NCAT (wears wig). R eye exotropia. R eye Sclera anicteric, MMM. Neck: Supple, no LAD Lungs: Breathing comfortably on 3L NC, no signs of accessory muscle use. CTAB, moving air throughout, mild crackles at L lung base. No wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no m/r/g Abdomen: Slightly taut in upper abdomen, moderately distended without fluid wave, liver edge 5cm below R costal margin, non-tender to percussion and deep palpation, no rebound tenderness or guarding, scar along R costal margin from prior open cholescytectomy Ext: WWP, 2+ pulses, no clubbing, cyanosis or peripheral edema Skin: Xerosis on bilateral shins Neuro: A&Ox3, motor function grossly normal Pertinent Results: >> ADMISSION LABS: ___ 05:35AM BLOOD Hgb-7.8* ___ 12:30PM BLOOD WBC-5.8 RBC-2.50* Hgb-7.4* Hct-25.0* MCV-100* MCH-29.6 MCHC-29.6* RDW-22.5* RDWSD-79.8* Plt ___ ___ 12:30PM BLOOD Neuts-58.2 ___ Monos-14.4* Eos-2.8 Baso-0.7 NRBC-0.3* Im ___ AbsNeut-3.37 AbsLymp-1.35 AbsMono-0.83* AbsEos-0.16 AbsBaso-0.04 ___ 12:30PM BLOOD ___ PTT-33.6 ___ ___ 12:30PM BLOOD Plt ___ ___ 12:30PM BLOOD Glucose-104* UreaN-17 Creat-2.4*# Na-136 K-3.5 Cl-96 HCO3-32 AnGap-12 ___ 12:30PM BLOOD ALT-29 AST-49* LD(___)-156 AlkPhos-176* TotBili-0.9 ___ 12:30PM BLOOD cTropnT-0.01 ___ 12:30PM BLOOD Albumin-3.4* Calcium-8.9 Phos-2.3* Mg-1.7 ___ 12:30PM BLOOD AFP-3.2 ___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:53PM BLOOD Lactate-1.3 . >> INTERVAL LABS: ___ 07:49AM BLOOD Ret Aut-4.7* Abs Ret-0.13* . >> DISCHARGE LABS: ___ 06:46AM BLOOD WBC-6.5 RBC-2.77* Hgb-8.2* Hct-28.0* MCV-101* MCH-29.6 MCHC-29.3* RDW-21.6* RDWSD-78.4* Plt ___ ___ 06:46AM BLOOD Plt ___ ___ 06:46AM BLOOD ___ PTT-33.2 ___ ___ 06:46AM BLOOD Glucose-93 UreaN-61* Creat-7.7*# Na-137 K-4.9 Cl-95* HCO3-28 AnGap-19 ___ 06:46AM BLOOD Calcium-9.5 Phos-5.8* Mg-2.1 . >> MICROBIOLOGY: Blood cultures ___: pending . >> IMAGING: ___ CXR FINDINGS: Overlying EKG leads are present. There is persistent mild cardiomegaly. Hilar congestion and moderate pulmonary edema is noted. Linear densities in the mid to lower lungs likely represent platelike atelectasis. Tiny effusions are likely present. No pneumothorax. Bony structures are intact. IMPRESSION: Moderate pulmonary edema. . ___ RUQ US IMPRESSION: 1. Enlarged liver, dilated IVC and hepatic veins are similar to before with a pulsatile waveform in the portal vein. Findings are consistent with right heart failure. 2. Heterogeneous echotexture of the liver is similar to before. Portal vein is patent. 3. Trace ascites. . ___ Upper GI endoscopy Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Erythema and erosions of the mucosa were noted in the antrum. These findings are compatible with erosive gastritis. Cold forceps biopsies were performed for histology at the antrum. Excavated Lesions 2 linear ulcerations were seen in the cardia without associated significant hiatal hernia Cold forceps biopsies were performed for histology at the cardia. Duodenum: Normal duodenum. Impression: Gastric ulcer (biopsy) Erythema and erosions in the antrum compatible with erosive gastritis (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: BID PPI until follow up endoscopy Follow up biopsies Repeat EGD in ___ weeks to follow up ulcerations in cardia. Would also recommend colonoscopy at the same time given prior colonoscopy prep was fair and a polyp was not removed at the time of her last colonoscopy Brief Hospital Course: Ms. ___ is a ___ y/o woman with anuric ESRD s/p renal transplant c/b allograft failure requiring HD ___, atrial fibrillation (not on anticoagulation given significant GI and AVF site bleeding, INR 1.2), diastolic CHF (EF>55% in ___, HTN, COPD (FEV1/FVC 86% in ___, on ___ home O2), pulmonary HTN, GERD, and recurrent C. diff colitis, admitted for post-dialysis hypotension, and acute on chronic anemia in the setting of melenotic stools x 1 week. . >> ACTIVE ISSUES: # Upper GI bleed: Patient with one week of melena, acute drop in Hb consistent with likely upper GI bleed. History of GERD but no PUD. She does note some ABD pain on exam. Her ABD is distended, which she says always happens (along with pain) after eating ice. Patient had one prior GIB in setting of anticoagulation for a fib, but source never identified. GI consulted in ED. She had an EGD in ___ which was normal. Imaging around the time of EGD was not suggestive of cirrhosis; however, in years since that EGD, she has developed an enlarged and coarsened liver. GI consulted in ED, no indication for intervention. Patient treated with BID IV Pantoprazole and had no further episodes of melena. She was discharged with plan for outpatient GI follow up and potential endoscopy. . # Acute on chronic anemia: Patient initially presented with Hgb 7.4, down from her baseline of 9. Her acute on chronic anemia was thought to be due to blood loss given melena x 1 week with contribution from known ESRD. Her Hgb increased to 8.1 after transfusion of 1U pRBC and remained stable. . # Hypotension: Patient initially presented with post-dialysis SBPs in 70-80s from baseline ___. Likely in setting of volume depletion from dialysis and ongoing GIB x 1 week. Less likely hypovolemia due to sepsis given patient is afebrile with no leukocytosis or signs of infection. Blood pressures improved s/p 1 unit of packed red blood cells in the Emergency Department and remained stable throughout remainder of admission. . # Hepatomegaly: Liver edge palpated 4-6 cm below the R costal margin with imaging suggestive of cirrhosis and congestive hepatopathy. She has negative hepatitis serologies, and remote history of heavy alcohol use in her ___. A more likely cause for hepatic congestion is her right sided heart failure, however. She has a slightly elevated INR, which may be secondary to poor nutritional intake given her age and comorbidities. Her liver function tests are largely within normal limits. RUQ US on ___ revealed enlarged liver with heterogeneous echotexture, unchanged from prior studies. She should have f/u of liver function with PCP, with consideration for referral to hepatology. . # Atrial Fibrillation: CHADS2-VASC score 3, not currently on anticoagulation given history of GI and AV fistula bleed. She was monitored on telemetry and remained in atrial fibrillation. Metoprolol was held during this admission in the setting of hypotension. Per GI, there is no long-term contraindication to anticoagulation but would start after EGD. . >> CHRONIC ISSUES: # Anuric End-Stage Renal Disease s/p cadaveric donor renal transplant complicated by allograft failure, re-initiated on HD ___. Last dialysis session on ___ with CXR showing moderate pulmonary edema. Patient continued taking herhome Nephrocaps, Cinacalcet, and Calcium Acetate during this admission and was on a renal diet. . # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in ___ ___s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Patient mildly volume up on exam, but satting well on home O2 requirement. . # Chronic obstructive pulmonary disease: Patient last had pulmonary function testing in ___, which showed moderately reduced FVC, moderately severe reduction in FEV1, with elevated FEV1/FVC, thought to reflect moderately severe obstructive disease. She was monitored with O2 Telemetry during this admission. She continued taking her home Albuterol neb Q4H as needed and Advair (250/50) twice a day. She continued using her home oxygen ___ NC). . # GERD: Patient takes PO omeprazole 40mg QD at home, was switched to IV pantoprazole 40mg BID on admission in setting of melena, then switched back to PO pantoprazole 40mg BID upon discharge. . # ESRD: HD ___ as outpatient. Last dialysis session ___. # Pending Labs: Please f/u blood culture x 2, negative growth pending discharge. # Hepatomegaly: Appreciated on exam, with RUQUS congestive hepatopathy. Please continue to trend, and workup liver disease as outpatient. # COPD: Patient continued on home continuous ___ without any desaturation. # Code: Full (confirmed) # Communication: ___ (sister and HCP) ___ >> TRANSITIONAL ISSUES: # GI bleed: [ ] Patient needs repeat EGD in ___ weeks to follow up on ulcerations in cardia. [ ] Would recommend colonoscopy at same time given prior colonoscopy (___) prep was fair and revealed an 8mm sessile polyp that was not removed. [ ] BID PPI until follow-up endoscopy. [ ] Follow-up biopsies from ___ EGD. . # Atrial fibrillation: [ ] ___ consider initiation of anti-coagulation after follow-up EGD as no long-term contraindications from GI. . Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 3. Nephrocaps 1 CAP PO DAILY 4. albuterol sulfate 90 mcg/actuation inhalation Q6H 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Calcium Acetate 667 mg PO TID W/MEALS 8. Omeprazole 40 mg PO DAILY 9. terconazole 0.8 % vaginal QHS:PRN vaginitis Discharge Medications: 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 6. Nephrocaps 1 CAP PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Upper GI bleed 2. Erosive gastritis 3. Gastric ulcers SECONDARY DIAGNOSIS: 1. Hypotension 2. Acute on chronic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted to the hospital because of low blood pressure, low red blood cell count, and dark stool positive for blood (melena). Your symptoms were thought to be due to bleeding in your gastrointestinal tract. You were treated with an intravenous proton-pump inhibitor (pantoprazole) to decrease stomach acidity. You underwent upper endoscopy study to look for possible source of bleeding, which showed ulcers in your stomach and inflammation of your stomach lining (gastritis). Biopsies of your stomach tissue were taken, results of which are pending. We would like you to continue taking pantoprazole twice a day to help protect your stomach lining, and to return for a repeat endoscopy in ___ weeks to assess for healing of the ulcers, with colonoscopy at the same time. Please continue taking your home medications. Please follow-up with your PCP and outpatient specialists on discharge. We wish you a speedy recovery, Your ___ care team Followup Instructions: ___
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Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: [MASKED] Upper GI endoscopy History of Present Illness: Ms. [MASKED] is a [MASKED] y/o woman with past history of ESRD s/p transplant on HD ([MASKED]), COPD, GERD (w/out PUD), atrial fibrillation not on coumadin, recurrent cdiff infection presents with hypotension and worsening anemia in setting of melena. Patient reports dark, painless stools for approximately one week. Underwent HD on morning of admission and was noted to have Hb 7.8 (down from baseline [MASKED] and hypotensive to SBP 70-80's. Baseline SBP in 90's post dialysis. She denies fevers, chills, chest pain, sob, abdominal pain, nausea, vomiting, dysuria, frequency, diarrhea. Of note, patient previously trialed on anticoagulation for atrial fibrillation, but experienced massive GIB without source being identified (underwent endoscopy, capsule). In the ED, initial vitals: T 98.0, P 95, BP 82/41 RR 16 O2 99% RA - Exam notable for rectal exam with melena. - Labs were notable for: Hb 7.4 (b/l [MASKED], lactate 1.3. trop<0.01, phos 2.3. Remainder electrolytes wnl. Serum tox negative. - Imaging: CXR showed moderate pulmonary edema. - Patient was given: IV Pantoprazole 80mg IV, 1u PRBC's - Consults: GI Admitted to MICU given hypotension and multiple comorbidities. On arrival to the MICU, she reports feeling well and at her baseline. She says she would otherwise be driving to the store to grocery shop. She does note some dark brown stools but denies seeing frank black stools. She denies dizziness, lightheadedness, chest pain, or SOB that is worse than baseline. She wear 2L of home O2. She has not had any medication changes preceding this admission. She denies confusion at home, falls, or vomiting. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant in - FSGS by biopsy, on HD [MASKED]. s/p DCDKD in [MASKED] c/b chronic allograft nephropathy in [MASKED] with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on [MASKED] home oxygen; FEV1 of 57% predicted [MASKED] - Diastolic CHF - Last TTE in [MASKED] with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in [MASKED] and treated with flagyl 500mg x 10 days; again in [MASKED] s/p flagyl 500mg x 14 days, persistent infection still later in [MASKED], treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy [MASKED] - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: [MASKED] Family History: Mother on dialysis from DM. Niece with ESRD, s/p transplant Physical Exam: >> ADMISSION EXAM: Vitals: 92/56 HR79 O2 98% on 2L HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: mild inspiratory and expiratory wheezes throughout. CV: Irregularly irregular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Distended, TTP throughout [MASKED] her stomach. bowel sounds present, Enlarged liver. EXT: Warm, well perfused, 2+ pulses, trace [MASKED]. NEURO: CN II-XII grossly intact, moving all extremities appropriately. No asterxsis. ACCESS: LUE fistula, 2 PIVs. . >> DISCHARGE EXAM: Vitals: T 98.4, HR 81, BP 100-113/55-57, RR 18, SpO2 100% on 3L NC General: Sitting up in bed, moving about room. HEENT: NCAT (wears wig). R eye exotropia. R eye Sclera anicteric, MMM. Neck: Supple, no LAD Lungs: Breathing comfortably on 3L NC, no signs of accessory muscle use. CTAB, moving air throughout, mild crackles at L lung base. No wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no m/r/g Abdomen: Slightly taut in upper abdomen, moderately distended without fluid wave, liver edge 5cm below R costal margin, non-tender to percussion and deep palpation, no rebound tenderness or guarding, scar along R costal margin from prior open cholescytectomy Ext: WWP, 2+ pulses, no clubbing, cyanosis or peripheral edema Skin: Xerosis on bilateral shins Neuro: A&Ox3, motor function grossly normal Pertinent Results: >> ADMISSION LABS: [MASKED] 05:35AM BLOOD Hgb-7.8* [MASKED] 12:30PM BLOOD WBC-5.8 RBC-2.50* Hgb-7.4* Hct-25.0* MCV-100* MCH-29.6 MCHC-29.6* RDW-22.5* RDWSD-79.8* Plt [MASKED] [MASKED] 12:30PM BLOOD Neuts-58.2 [MASKED] Monos-14.4* Eos-2.8 Baso-0.7 NRBC-0.3* Im [MASKED] AbsNeut-3.37 AbsLymp-1.35 AbsMono-0.83* AbsEos-0.16 AbsBaso-0.04 [MASKED] 12:30PM BLOOD [MASKED] PTT-33.6 [MASKED] [MASKED] 12:30PM BLOOD Plt [MASKED] [MASKED] 12:30PM BLOOD Glucose-104* UreaN-17 Creat-2.4*# Na-136 K-3.5 Cl-96 HCO3-32 AnGap-12 [MASKED] 12:30PM BLOOD ALT-29 AST-49* LD([MASKED])-156 AlkPhos-176* TotBili-0.9 [MASKED] 12:30PM BLOOD cTropnT-0.01 [MASKED] 12:30PM BLOOD Albumin-3.4* Calcium-8.9 Phos-2.3* Mg-1.7 [MASKED] 12:30PM BLOOD AFP-3.2 [MASKED] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:53PM BLOOD Lactate-1.3 . >> INTERVAL LABS: [MASKED] 07:49AM BLOOD Ret Aut-4.7* Abs Ret-0.13* . >> DISCHARGE LABS: [MASKED] 06:46AM BLOOD WBC-6.5 RBC-2.77* Hgb-8.2* Hct-28.0* MCV-101* MCH-29.6 MCHC-29.3* RDW-21.6* RDWSD-78.4* Plt [MASKED] [MASKED] 06:46AM BLOOD Plt [MASKED] [MASKED] 06:46AM BLOOD [MASKED] PTT-33.2 [MASKED] [MASKED] 06:46AM BLOOD Glucose-93 UreaN-61* Creat-7.7*# Na-137 K-4.9 Cl-95* HCO3-28 AnGap-19 [MASKED] 06:46AM BLOOD Calcium-9.5 Phos-5.8* Mg-2.1 . >> MICROBIOLOGY: Blood cultures [MASKED]: pending . >> IMAGING: [MASKED] CXR FINDINGS: Overlying EKG leads are present. There is persistent mild cardiomegaly. Hilar congestion and moderate pulmonary edema is noted. Linear densities in the mid to lower lungs likely represent platelike atelectasis. Tiny effusions are likely present. No pneumothorax. Bony structures are intact. IMPRESSION: Moderate pulmonary edema. . [MASKED] RUQ US IMPRESSION: 1. Enlarged liver, dilated IVC and hepatic veins are similar to before with a pulsatile waveform in the portal vein. Findings are consistent with right heart failure. 2. Heterogeneous echotexture of the liver is similar to before. Portal vein is patent. 3. Trace ascites. . [MASKED] Upper GI endoscopy Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Erythema and erosions of the mucosa were noted in the antrum. These findings are compatible with erosive gastritis. Cold forceps biopsies were performed for histology at the antrum. Excavated Lesions 2 linear ulcerations were seen in the cardia without associated significant hiatal hernia Cold forceps biopsies were performed for histology at the cardia. Duodenum: Normal duodenum. Impression: Gastric ulcer (biopsy) Erythema and erosions in the antrum compatible with erosive gastritis (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: BID PPI until follow up endoscopy Follow up biopsies Repeat EGD in [MASKED] weeks to follow up ulcerations in cardia. Would also recommend colonoscopy at the same time given prior colonoscopy prep was fair and a polyp was not removed at the time of her last colonoscopy Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o woman with anuric ESRD s/p renal transplant c/b allograft failure requiring HD [MASKED], atrial fibrillation (not on anticoagulation given significant GI and AVF site bleeding, INR 1.2), diastolic CHF (EF>55% in [MASKED], HTN, COPD (FEV1/FVC 86% in [MASKED], on [MASKED] home O2), pulmonary HTN, GERD, and recurrent C. diff colitis, admitted for post-dialysis hypotension, and acute on chronic anemia in the setting of melenotic stools x 1 week. . >> ACTIVE ISSUES: # Upper GI bleed: Patient with one week of melena, acute drop in Hb consistent with likely upper GI bleed. History of GERD but no PUD. She does note some ABD pain on exam. Her ABD is distended, which she says always happens (along with pain) after eating ice. Patient had one prior GIB in setting of anticoagulation for a fib, but source never identified. GI consulted in ED. She had an EGD in [MASKED] which was normal. Imaging around the time of EGD was not suggestive of cirrhosis; however, in years since that EGD, she has developed an enlarged and coarsened liver. GI consulted in ED, no indication for intervention. Patient treated with BID IV Pantoprazole and had no further episodes of melena. She was discharged with plan for outpatient GI follow up and potential endoscopy. . # Acute on chronic anemia: Patient initially presented with Hgb 7.4, down from her baseline of 9. Her acute on chronic anemia was thought to be due to blood loss given melena x 1 week with contribution from known ESRD. Her Hgb increased to 8.1 after transfusion of 1U pRBC and remained stable. . # Hypotension: Patient initially presented with post-dialysis SBPs in 70-80s from baseline [MASKED]. Likely in setting of volume depletion from dialysis and ongoing GIB x 1 week. Less likely hypovolemia due to sepsis given patient is afebrile with no leukocytosis or signs of infection. Blood pressures improved s/p 1 unit of packed red blood cells in the Emergency Department and remained stable throughout remainder of admission. . # Hepatomegaly: Liver edge palpated 4-6 cm below the R costal margin with imaging suggestive of cirrhosis and congestive hepatopathy. She has negative hepatitis serologies, and remote history of heavy alcohol use in her [MASKED]. A more likely cause for hepatic congestion is her right sided heart failure, however. She has a slightly elevated INR, which may be secondary to poor nutritional intake given her age and comorbidities. Her liver function tests are largely within normal limits. RUQ US on [MASKED] revealed enlarged liver with heterogeneous echotexture, unchanged from prior studies. She should have f/u of liver function with PCP, with consideration for referral to hepatology. . # Atrial Fibrillation: CHADS2-VASC score 3, not currently on anticoagulation given history of GI and AV fistula bleed. She was monitored on telemetry and remained in atrial fibrillation. Metoprolol was held during this admission in the setting of hypotension. Per GI, there is no long-term contraindication to anticoagulation but would start after EGD. . >> CHRONIC ISSUES: # Anuric End-Stage Renal Disease s/p cadaveric donor renal transplant complicated by allograft failure, re-initiated on HD [MASKED]. Last dialysis session on [MASKED] with CXR showing moderate pulmonary edema. Patient continued taking herhome Nephrocaps, Cinacalcet, and Calcium Acetate during this admission and was on a renal diet. . # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in [MASKED] s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Patient mildly volume up on exam, but satting well on home O2 requirement. . # Chronic obstructive pulmonary disease: Patient last had pulmonary function testing in [MASKED], which showed moderately reduced FVC, moderately severe reduction in FEV1, with elevated FEV1/FVC, thought to reflect moderately severe obstructive disease. She was monitored with O2 Telemetry during this admission. She continued taking her home Albuterol neb Q4H as needed and Advair (250/50) twice a day. She continued using her home oxygen [MASKED] NC). . # GERD: Patient takes PO omeprazole 40mg QD at home, was switched to IV pantoprazole 40mg BID on admission in setting of melena, then switched back to PO pantoprazole 40mg BID upon discharge. . # ESRD: HD [MASKED] as outpatient. Last dialysis session [MASKED]. # Pending Labs: Please f/u blood culture x 2, negative growth pending discharge. # Hepatomegaly: Appreciated on exam, with RUQUS congestive hepatopathy. Please continue to trend, and workup liver disease as outpatient. # COPD: Patient continued on home continuous [MASKED] without any desaturation. # Code: Full (confirmed) # Communication: [MASKED] (sister and HCP) [MASKED] >> TRANSITIONAL ISSUES: # GI bleed: [ ] Patient needs repeat EGD in [MASKED] weeks to follow up on ulcerations in cardia. [ ] Would recommend colonoscopy at same time given prior colonoscopy ([MASKED]) prep was fair and revealed an 8mm sessile polyp that was not removed. [ ] BID PPI until follow-up endoscopy. [ ] Follow-up biopsies from [MASKED] EGD. . # Atrial fibrillation: [ ] [MASKED] consider initiation of anti-coagulation after follow-up EGD as no long-term contraindications from GI. . Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 3. Nephrocaps 1 CAP PO DAILY 4. albuterol sulfate 90 mcg/actuation inhalation Q6H 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Calcium Acetate 667 mg PO TID W/MEALS 8. Omeprazole 40 mg PO DAILY 9. terconazole 0.8 % vaginal QHS:PRN vaginitis Discharge Medications: 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 6. Nephrocaps 1 CAP PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Upper GI bleed 2. Erosive gastritis 3. Gastric ulcers SECONDARY DIAGNOSIS: 1. Hypotension 2. Acute on chronic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you during your hospitalization at [MASKED]. You were admitted to the hospital because of low blood pressure, low red blood cell count, and dark stool positive for blood (melena). Your symptoms were thought to be due to bleeding in your gastrointestinal tract. You were treated with an intravenous proton-pump inhibitor (pantoprazole) to decrease stomach acidity. You underwent upper endoscopy study to look for possible source of bleeding, which showed ulcers in your stomach and inflammation of your stomach lining (gastritis). Biopsies of your stomach tissue were taken, results of which are pending. We would like you to continue taking pantoprazole twice a day to help protect your stomach lining, and to return for a repeat endoscopy in [MASKED] weeks to assess for healing of the ulcers, with colonoscopy at the same time. Please continue taking your home medications. Please follow-up with your PCP and outpatient specialists on discharge. We wish you a speedy recovery, Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "D62", "I5032", "I4891", "J449", "D649", "F17210", "K219" ]
[ "K921: Melena", "N186: End stage renal disease", "T8619: Other complication of kidney transplant", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I953: Hypotension of hemodialysis", "D62: Acute posthemorrhagic anemia", "I5032: Chronic diastolic (congestive) heart failure", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "Z940: Kidney transplant status", "I272: Other secondary pulmonary hypertension", "Z992: Dependence on renal dialysis", "I4891: Unspecified atrial fibrillation", "J449: Chronic obstructive pulmonary disease, unspecified", "K2960: Other gastritis without bleeding", "R160: Hepatomegaly, not elsewhere classified", "D649: Anemia, unspecified", "K635: Polyp of colon", "Z9981: Dependence on supplemental oxygen", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8619: Personal history of other infectious and parasitic diseases", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,055,694
22,141,743
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with past history of ESRD s/p transplant now on dialysis ___ (anuric), last received dialsis on ___, COPD on 3L home O2, atrial fibrillation (not on anticoagulation), she presented with 2 days of shortness of breath and back pain which has been worsening. She was in her normal state of health at her dialysis on ___. On ___ she endorsed a productive cough (no sick contacts, fevers, but subjective chills) and some back pain which she initially described as a constant burning throughout her whole back. This sensation has now resolved. Denies CP, worsening orthopnea. In the ED, initial vitals: 0 99.0 ___ 18 99% Nasal Cannula. She had one rectal temp of 100.4 early on the morning of admission. - Exam notable for diffuse crackles on pulmonary examination. - Labs were notable for WBC 6.8, HgB 8.9 Hct 29, Platelet 189. INR 1.3. Serum ASA 8.4, Serum APAP 31. Lactate 1.0. - Imaging showed: Negative CTA for PE, multiple intrathoracic lymph nodes. Bedside U/S showed no pericardial effusion. - Patient was given: ___ 06:10 PR Acetaminophen 650 mg ___ 06:23 IH Albuterol 0.083% Neb Soln 1 NEB ___ 06:23 IH Ipratropium Bromide Neb 1 NEB ___ 06:23 IV Vancomycin 1000 mg ___ 06:23 IVF 1000 mL NS 500 mL ___ 07:12 IV Insulin Regular 10 units ___ 07:12 IV Dextrose 50% 25 gm ___:43 IV Calcium Gluconate 1 gm ___ 07:54 IV Levofloxacin 750 mg ___ 12:25 PO Metoprolol Succinate XL 25 mg - Consults: Renal, recommended possible CRRT vs. IHD today depending on blood pressure stability. Recommended empiric treatment for HCAP. On arrival to the MICU, she confirmed the above story stating that her burning back pain has now dissipated. She denies any increased shortness of breath. She endorses continued diarrhea ___ daily, but denies any abdominal pain. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant in - FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in ___ and treated with flagyl 500mg x 10 days; again in ___ s/p flagyl 500mg x 14 days, persistent infection still later in ___, treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother was on dialysis from DM. Niece has ESRD, s/p transplant Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: T: 97.9 BP: 124/78 P: 89 Sp02: 91% on RA. GENERAL: Lethargic but arousable, falling asleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: On RA, mild increase work of breathing, fair air exchange, crackles and wheezes in lower to mid lung fields. CV: Irregularly irregular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, slightly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, mild ___ edema 1+ to ankles. NEURO: CN II-XII grossly intact, moving all extremities appropriately. ACCESS: LUE fistula, 2 PIVs DISCHARGE PHYSICAL EXAM: =========================== VS: 98.3, 90/47, 69, 20, 98% RA I/O: -3L during HD Gen: Well nourished appearing, dark-skinned woman, sitting up in bed in NAD HEENT: NT/AT, white hair, disconjugate gaze; mild scleral icterus, EOMI (both eyes track, but right eye unable to pass midline/this is her baseline), PERRLA, MMM moist but tongue coated in thick white/yellow plaques (improved compared to prior day) Neck: supple, symmetric, no AC, PC, or supraclavicular chain LAD; JVP difficult to assess I/s/o afib, but external jugular vein very prominent on exam today CV: variable S1, S2; regular rate; no m/r/g Pulm: breathing comfortably on NC, with slightly increased rate and mildly increased WOB; good air movement throughout posteriorly; bronchial breath sounds in b/l bases; no frank wheezes, rhonchi, or crackles Abd: Soft, mildly distended, non-rigid, mildly tender to palpation diffusely, worst in the epigastrium; no r/g; BS+ Ext: Warm, well-perfused, no pitting edema in BLE; DP palpable b/l Skin: no appreciable rashes; hyperpigmented scar in RUQ from prior cholecystectomy; hypopigmented skin over recently accessed LUE AVF Neuro: Alert, interactive on exam; no gross deficits appreciated ACCESS: PIV, LUE AVF (with palpable thrill) Pertinent Results: ADMISSION LABS: ___ 05:50AM BLOOD WBC-6.8 RBC-3.09* Hgb-8.9* Hct-28.5* MCV-92 MCH-28.8 MCHC-31.2* RDW-18.5* RDWSD-60.7* Plt ___ ___ 05:50AM BLOOD Neuts-54.3 ___ Monos-14.5* Eos-1.6 Baso-0.9 Im ___ AbsNeut-3.66 AbsLymp-1.91 AbsMono-0.98* AbsEos-0.11 AbsBaso-0.06 ___ 05:50AM BLOOD ___ PTT-34.5 ___ ___ 05:50AM BLOOD Glucose-92 UreaN-72* Creat-7.6* Na-137 K-7.0* Cl-96 HCO3-29 AnGap-19 ___ 05:50AM BLOOD ALT-14 AST-26 AlkPhos-149* TotBili-0.9 ___ 05:50AM BLOOD Lipase-31 ___ 05:50AM BLOOD cTropnT-0.01 ___ 05:50AM BLOOD Albumin-3.6 Calcium-9.7 Phos-2.6*# Mg-1.9 ___ 05:50AM BLOOD ASA-8.4 Ethanol-NEG Acetmnp-13 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:59AM BLOOD Lactate-1.0 OTHER IMPORTANT LABS: None MICROBIOLOGY: ___ Influenza A: Positive ___ Influenza B: Negative ___ Blood Culture x2: NGTD, pending ___ Blood Culture x2: NGTD, pending ___ HIV Serologies: Negative ___ H.Pylori Serologies: Pending at time of discharge IMAGING AND OTHER STUDIES: ___ CTA Chest: 1. Mild pulmonary edema. 2. Cardiomegaly, moderate with biatrial chamber enlargement. 3. Innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. Clinical correlation is advised. 4. No pulmonary embolism or acute aortic dissection. 5. Partially visualized abdominal ascites. ___ Portable CXR: Bilateral airspace opacities with a central predominance likely reflect pulmonary vascular congestion and mild pulmonary edema. Difficult to exclude superimposed infection in the appropriate clinical setting. ___ RUQ Ultrasound: 1. Enlarged liver along with a dilated IVC and hepatic veins is concerning for underlying fluid overload. This may also be seen in right heart failure. 2. Slightly heterogeneous and coarsened liver echotexture. No focal lesions. No intrahepatic biliary ductal dilation. 3. Trace ascites. DISCHARGE LABS: ___ 09:30AM BLOOD WBC-6.2 RBC-2.92* Hgb-8.4* Hct-28.0* MCV-96 MCH-28.8 MCHC-30.0* RDW-18.6* RDWSD-65.1* Plt ___ ___ 07:16AM BLOOD ___ PTT-32.0 ___ ___ 07:16AM BLOOD Glucose-95 UreaN-24* Creat-5.4*# Na-140 K-4.4 Cl-96 HCO3-34* AnGap-14 ___ 07:16AM BLOOD ALT-30 AST-51* LD(LDH)-214 AlkPhos-157* TotBili-0.8 ___ 07:16AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ y/o woman with past history of ESRD s/p transplant on HD (___), COPD, and recurrent C. diff infection, presenting with volume overload and influenza. She had a brief FICU stay for urgent HD, was transferred to the floor with improving respiratory and volume status, and monitored closely for downtrending Hgb and reported melena prior to discharge home. ACTIVE ISSUES: -------------------- # Hypoxia of Multifactorial Etiology: The patient presented with hypoxia likely due to combination of fluid overload in setting of known CHF, ESRD, COPD, and active influenza A infection. Her active afib with intermittent RVR was likely further worsening her respiratory status. With management of these individual problems, as detailed below, her respiratory status improved and she was discharged on her home O2 requirement of ___ by NC. # Influenza A Infection: The patient was found to be FluA positive per PCR on admission and started on Tamiflu for ___ue to HD dosing (___). She did have infectious work-up for potential superinfection with PNA, but chest imaging was without notable findings. She was briefly on empiric abx and had blood cultures drawn, with no growth at time of discharge. # Anemia of unclear etiology: At baseline, the patient had a hemoglobin of ~9, likely due to ESRD. The patient did not appear malnourished on exam, but of note, nutritional studies had not been performed in several years. As detailed below, there was concern for underlying liver disease in this patient, which could have been contributing to her overall anemia. Additionally, active influenza infection could possibly have caused transient myelosuppression. During this admission, the patient further endorsed black stool (new for several days prior to and during this admission) and was found to be guaiac positive in the FICU. With trending, her hemoglobin did downtrend from her baseline to 7.7 at time of transfer to the general medicine service, concerning for upper GI bleed especially given her prior history of bleeding. She was briefly put on IV PPI and had H.Pylori serologies sent. The patient was found still to be guaiac positive but without melena on rectal exam and her hemoglobin did return to her baseline prior to discharge. The patient was arranged for outpatient follow-up with GI for further evaluation of possible GI bleed. She was also instructed to follow up with her outpatient providers regarding results of her H.Pylori serologies. # Anuric End-Stage Renal Disease s/p DCDRT complicated by allograft failure, re-initiated on HD: The patient has had a history of ESRD since ___, initially on HD. She underwent DCDRT in ___, with subsequent allograft failure and re-initiation on HD in ___. She has an estimated dry weight of ~66kg and was continued on her home ___ HD schedule. She was also continued on her home calcium supplements and phosphorus binders. She was followed closely by the renal HD service during this admission and discharged home following her last dialysis session on ___ at her dry weight of 66.2kg. # Recurrent C. Diff Colitis: The patient has failed multiple courses of treatment for C diff Colitis and was treated for another episode of recurrent C. Diff during this admission. She was initiated on Vancomycin 125mg PO q6H and Flagyl 500mg IV q8H on ___ while in the ICU and continued on a planned 14 day course of PO Vancomycin. She was discharged home with enough Vancomycin capsules to complete her 14 days course (last dose on ___. She should also follow up with her PCP and GI about potentially pursuing stool transplant given her multiple relapses. # Atrial Fibrillation: The patient has had a history of poorly controlled afib due to inability to effectively rate control in the setting of intradialytic hypotension. She was rate controlled with fractionated metoprolol equivalent in dosage to her home metoprolol XL 25mg PO daily during this admission. She was continued on ASA 81mg PO daily for stroke prophylaxis during this admission as she has been unable to tolerate systmic anticoagulation in the setting of active and prior GI bleeding as well as prior AV Fistula site bleeding (despite a CHADS2VASC of ___. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in ___ ___s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Her CHF was felt to be a major contributor to her overall volume overload, which improved with treatment of her influenza and dialysis. # COPD on Home O2: The patient has PFTs from ___ c/w restrictive lung disease but prior PFTs showing obstructive disease. She was continued on her home inhaler regimen with added duonebs PRN and discharged on her home oxygen regimen of ___ per NC. # Mediastinal Lymphadenopathy: The patient was noted to have mediastinal LAD on chest imaging, likely reactive due to influenza. However, there was concern given poor follow that this could be due to an alternate etiology such as lymphoma or perhaps sarcoidosis. Initial work-up in the hospital was unrevealing with normal LDH and negative ACE levels. Her 1,25 hydroxy Vitamin D levels to evaluate for Sarcoidosis were still pending at time of discharge. She was instructed to follow up with her PCP regarding results of this test and she should had repeat Chest CT to re-evaluate for finding of mediastinal lymphadenopathy. # Thrush: The patient was found to have thrush on exam during this admission, likely due to underlying ESRD as well as use of oral steroid inhalers. She was provided nystatin swish and spit with improvement in her thrush. She also had HIV serologies re-sent, which were still pending at time of discharge. She should follow up with her PCP regarding results of this test. #Hypertension: The patient has history a history of hypertension with blood pressures largely within normal limits during this admission. She did have low blood pressures, likely triggered by dialysis. She responded well to gentle intravenous fluid boluses in the setting of her tenuous respiratory status. She was continued on her fractionated metoprolol and her fluid status was managed with HD as above. Her blood pressures were normal at time of discharge. CHRONIC/STABLE/RESOLVED ISSUES: # Concern for Underlying Liver Disease: The patient was admitted with elevated transaminases and INR as well as history of concern for underlying liver disease. She had CT in ___ showing nodular liver disease and perihepatic ascites. Prior Hep A,B,C studies negative with Hep A/C negative as recently as ___. The patient had RUQUS this admission, showing signs of congestive hepatopathy suggesting acute contribution from her volume overload. However, cirrhosis could not be ruled out. Her transaminases were monitored closely during this admission and she was treated for her CHF and ESRD as above. With these measures, her liver function tests downtrended prior to admission. She should have further work-up for possible cirrhosis as an outpatient. #GERD: The patient was admitted on oral PPI therapy, which was briefly changed to IV PPI due to concern over active GI bleeding. As above, her H&H stabilized and she was resumed on her home omeprazole prior to discharge. #Breast Cysts: The patient has a history of breast cysts and was continued on her home topical clindamycin throughout this admission. TRANSITIONAL ISSUES: -The patient had >1 point hemoglobin drop with self-reported melena and guaiac positive stool. As her blood counts stabilized prior to discharge, she did not receive further work-up as an inpatient. She should follow-up with GI after discharge for further evaluation. -The patient should have repeat CBC drawn on ___ with results faxed to Dr. ___ (PCP, fax number: ___ -As part of work-up for GI Bleed, the patient had H.Pylori serologies sent during this admission. Results were still pending at time of discharge and the patient should follow up on these with her PCP. -The patient was discharged with instructions to complete 14-day course of Vancomycin 125mg PO q6H for her recurrent C. Diff Colitis (First dose on ___ last dose on ___ -Given the patient's recurrent C Diff Colitis, the patient should be arranged for stool transplant evaluation -The patient should follow up with Dr. ___ (Pulmonology) for management of her Pulmonary Hypertension -The patient received hemodialysis per her home schedule of ___. Her last HD session was on ___. -On discharge, the patient's dry weight was 66.2kg -The patient should follow up with her outpatient Nephrologist regarding further management of her ESRD. Given her history of hypotension during dialysis, would consider potentially starting patient on Midodrine or other form of blood pressure support on dialysis days. -During this admission, the patient had elevated LFTs and mild markers of synthetic liver dysfunction. He had RUQ Ultrasound showing likely congestive hepatopathy but cirrhosis was not ruled out. She should have further work-up for cirrhosis as an outpatient. -The patient was found to have incidental finding of mediastinal lymphadenopathy on CTA of the Chest this admission. This should be followed up with repeat CT as an outpatient. Inpatient work-up for possible sarcoidosis was initiated with 1,25-OH Vitamin D levels (pending at time of discharge). This should be followed up with her PCP ___ pulmonologist. -The patient was discharged on her home O2 requirement of ___ liters per nasal cannula -Patient was discharged home on PO nystatin for thrush, likely due to inhaled corticosteroid use -The patient has endorsed leg pain both prior to and during this admission, concerning for possible peripheral vascular disease. She should have formal ABI's to evaluate as an outpatient. -CODE STATUS: FULL CODE -DRY WEIGHT: 66.2kg Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Nephrocaps 1 CAP PO DAILY 3. Calcium Acetate 667 mg PO DAILY 4. Cinacalcet 60 mg PO DAILY 5. Clindamycin 1% Solution 1 Appl TP DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO Q6H Will need total 14 day course. First day ___ Last day ___. RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp #*39 Capsule Refills:*0 2. Clindamycin 1% Solution 1 Appl TP DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 5. Nephrocaps 1 CAP PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Refills:*0 7. albuterol sulfate 90 mcg/actuation inhalation Q6H 8. Aspirin 81 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Outpatient Lab Work Please draw repeat CBC on ___ and have results faxed to Dr. ___ at ___. Diagnosis: Anemia (ICD10: D64.9) 11. Calcium Acetate 667 mg PO TID W/MEALS 12. Omeprazole 40 mg PO DAILY 13. terconazole 0.8 % vaginal QHS:PRN vaginitis Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: -Hypoxia due to Influenza A Infection -Recurrent Clostridium Difficile Colitis -Anemia of unclear etiology -Thrombocytopenia of unclear etiology -End-Stage Renal Disease on Hemodialysis -Diastolic Congestive Heart Failure with Right Heart Failure -Mediastinal Lymphadenopathy without Clear Etiology -Thrush -Congestive Hepatopathy SECONDARY DIAGNOSIS/ES: -Atrial Fibrillation -Chronic Obstructive Pulmonary Disease on Home Oxygen -History of Kidney Transplant with Allograft Nephropathy/Failure -Gastroesophageal Reflux Disease -Hypertension -History of Breast Cysts Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you were having trouble breathing and were noted to have low blood pressures. You were initially cared for in the intensive care unit (ICU) because your potassium levels were high and needed urgent dialysis. In the ICU, you received 2 sessions of dialysis, which helped your breathing. As you were found to have the flu, you were treated with a medication called Tamiflu. You were also started on an antibiotic to treat your C Diff infection. Upon transferring to the general medicine service, you were found to have slowly decreasing blood counts. As you were having black stools, there was significant concern for an intestinal bleed. With close monitoring, your blood counts stabilized and you were sent home with instructions to follow up with the Gastroenterologists as an outpatient. Prior to discharge, you received 1 more dialysis session and were breathing more comfortably. You had also completed treatment for the flu. It is important that you continue to take your medications and follow up with your outpatient doctors ___ detailed in the rest of your discharge paperwork). It is also very important that you weigh yourself every morning and call your primary care physician if your weight changes by more than 3 lbs. Thank you for allowing us to be a part of your care, Your ___ Team Followup Instructions: ___
[ "J09X2", "N186", "I120", "B370", "A047", "I5032", "D696", "Z940", "K921", "Z720", "R0902", "K761", "Z992", "J449", "J45909", "I4891", "E875", "I953", "K219", "M109", "D631", "N6002", "N6001", "R601" ]
Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with past history of ESRD s/p transplant now on dialysis [MASKED] (anuric), last received dialsis on [MASKED], COPD on 3L home O2, atrial fibrillation (not on anticoagulation), she presented with 2 days of shortness of breath and back pain which has been worsening. She was in her normal state of health at her dialysis on [MASKED]. On [MASKED] she endorsed a productive cough (no sick contacts, fevers, but subjective chills) and some back pain which she initially described as a constant burning throughout her whole back. This sensation has now resolved. Denies CP, worsening orthopnea. In the ED, initial vitals: 0 99.0 [MASKED] 18 99% Nasal Cannula. She had one rectal temp of 100.4 early on the morning of admission. - Exam notable for diffuse crackles on pulmonary examination. - Labs were notable for WBC 6.8, HgB 8.9 Hct 29, Platelet 189. INR 1.3. Serum ASA 8.4, Serum APAP 31. Lactate 1.0. - Imaging showed: Negative CTA for PE, multiple intrathoracic lymph nodes. Bedside U/S showed no pericardial effusion. - Patient was given: [MASKED] 06:10 PR Acetaminophen 650 mg [MASKED] 06:23 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 06:23 IH Ipratropium Bromide Neb 1 NEB [MASKED] 06:23 IV Vancomycin 1000 mg [MASKED] 06:23 IVF 1000 mL NS 500 mL [MASKED] 07:12 IV Insulin Regular 10 units [MASKED] 07:12 IV Dextrose 50% 25 gm [MASKED]:43 IV Calcium Gluconate 1 gm [MASKED] 07:54 IV Levofloxacin 750 mg [MASKED] 12:25 PO Metoprolol Succinate XL 25 mg - Consults: Renal, recommended possible CRRT vs. IHD today depending on blood pressure stability. Recommended empiric treatment for HCAP. On arrival to the MICU, she confirmed the above story stating that her burning back pain has now dissipated. She denies any increased shortness of breath. She endorses continued diarrhea [MASKED] daily, but denies any abdominal pain. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant in - FSGS by biopsy, on HD [MASKED]. s/p DCDKD in [MASKED] c/b chronic allograft nephropathy in [MASKED] with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on [MASKED] home oxygen; FEV1 of 57% predicted [MASKED] - Diastolic CHF - Last TTE in [MASKED] with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in [MASKED] and treated with flagyl 500mg x 10 days; again in [MASKED] s/p flagyl 500mg x 14 days, persistent infection still later in [MASKED], treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy [MASKED] - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: [MASKED] Family History: Mother was on dialysis from DM. Niece has ESRD, s/p transplant Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: T: 97.9 BP: 124/78 P: 89 Sp02: 91% on RA. GENERAL: Lethargic but arousable, falling asleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: On RA, mild increase work of breathing, fair air exchange, crackles and wheezes in lower to mid lung fields. CV: Irregularly irregular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, slightly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, mild [MASKED] edema 1+ to ankles. NEURO: CN II-XII grossly intact, moving all extremities appropriately. ACCESS: LUE fistula, 2 PIVs DISCHARGE PHYSICAL EXAM: =========================== VS: 98.3, 90/47, 69, 20, 98% RA I/O: -3L during HD Gen: Well nourished appearing, dark-skinned woman, sitting up in bed in NAD HEENT: NT/AT, white hair, disconjugate gaze; mild scleral icterus, EOMI (both eyes track, but right eye unable to pass midline/this is her baseline), PERRLA, MMM moist but tongue coated in thick white/yellow plaques (improved compared to prior day) Neck: supple, symmetric, no AC, PC, or supraclavicular chain LAD; JVP difficult to assess I/s/o afib, but external jugular vein very prominent on exam today CV: variable S1, S2; regular rate; no m/r/g Pulm: breathing comfortably on NC, with slightly increased rate and mildly increased WOB; good air movement throughout posteriorly; bronchial breath sounds in b/l bases; no frank wheezes, rhonchi, or crackles Abd: Soft, mildly distended, non-rigid, mildly tender to palpation diffusely, worst in the epigastrium; no r/g; BS+ Ext: Warm, well-perfused, no pitting edema in BLE; DP palpable b/l Skin: no appreciable rashes; hyperpigmented scar in RUQ from prior cholecystectomy; hypopigmented skin over recently accessed LUE AVF Neuro: Alert, interactive on exam; no gross deficits appreciated ACCESS: PIV, LUE AVF (with palpable thrill) Pertinent Results: ADMISSION LABS: [MASKED] 05:50AM BLOOD WBC-6.8 RBC-3.09* Hgb-8.9* Hct-28.5* MCV-92 MCH-28.8 MCHC-31.2* RDW-18.5* RDWSD-60.7* Plt [MASKED] [MASKED] 05:50AM BLOOD Neuts-54.3 [MASKED] Monos-14.5* Eos-1.6 Baso-0.9 Im [MASKED] AbsNeut-3.66 AbsLymp-1.91 AbsMono-0.98* AbsEos-0.11 AbsBaso-0.06 [MASKED] 05:50AM BLOOD [MASKED] PTT-34.5 [MASKED] [MASKED] 05:50AM BLOOD Glucose-92 UreaN-72* Creat-7.6* Na-137 K-7.0* Cl-96 HCO3-29 AnGap-19 [MASKED] 05:50AM BLOOD ALT-14 AST-26 AlkPhos-149* TotBili-0.9 [MASKED] 05:50AM BLOOD Lipase-31 [MASKED] 05:50AM BLOOD cTropnT-0.01 [MASKED] 05:50AM BLOOD Albumin-3.6 Calcium-9.7 Phos-2.6*# Mg-1.9 [MASKED] 05:50AM BLOOD ASA-8.4 Ethanol-NEG Acetmnp-13 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 05:59AM BLOOD Lactate-1.0 OTHER IMPORTANT LABS: None MICROBIOLOGY: [MASKED] Influenza A: Positive [MASKED] Influenza B: Negative [MASKED] Blood Culture x2: NGTD, pending [MASKED] Blood Culture x2: NGTD, pending [MASKED] HIV Serologies: Negative [MASKED] H.Pylori Serologies: Pending at time of discharge IMAGING AND OTHER STUDIES: [MASKED] CTA Chest: 1. Mild pulmonary edema. 2. Cardiomegaly, moderate with biatrial chamber enlargement. 3. Innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. Clinical correlation is advised. 4. No pulmonary embolism or acute aortic dissection. 5. Partially visualized abdominal ascites. [MASKED] Portable CXR: Bilateral airspace opacities with a central predominance likely reflect pulmonary vascular congestion and mild pulmonary edema. Difficult to exclude superimposed infection in the appropriate clinical setting. [MASKED] RUQ Ultrasound: 1. Enlarged liver along with a dilated IVC and hepatic veins is concerning for underlying fluid overload. This may also be seen in right heart failure. 2. Slightly heterogeneous and coarsened liver echotexture. No focal lesions. No intrahepatic biliary ductal dilation. 3. Trace ascites. DISCHARGE LABS: [MASKED] 09:30AM BLOOD WBC-6.2 RBC-2.92* Hgb-8.4* Hct-28.0* MCV-96 MCH-28.8 MCHC-30.0* RDW-18.6* RDWSD-65.1* Plt [MASKED] [MASKED] 07:16AM BLOOD [MASKED] PTT-32.0 [MASKED] [MASKED] 07:16AM BLOOD Glucose-95 UreaN-24* Creat-5.4*# Na-140 K-4.4 Cl-96 HCO3-34* AnGap-14 [MASKED] 07:16AM BLOOD ALT-30 AST-51* LD(LDH)-214 AlkPhos-157* TotBili-0.8 [MASKED] 07:16AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8 Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o woman with past history of ESRD s/p transplant on HD ([MASKED]), COPD, and recurrent C. diff infection, presenting with volume overload and influenza. She had a brief FICU stay for urgent HD, was transferred to the floor with improving respiratory and volume status, and monitored closely for downtrending Hgb and reported melena prior to discharge home. ACTIVE ISSUES: -------------------- # Hypoxia of Multifactorial Etiology: The patient presented with hypoxia likely due to combination of fluid overload in setting of known CHF, ESRD, COPD, and active influenza A infection. Her active afib with intermittent RVR was likely further worsening her respiratory status. With management of these individual problems, as detailed below, her respiratory status improved and she was discharged on her home O2 requirement of [MASKED] by NC. # Influenza A Infection: The patient was found to be FluA positive per PCR on admission and started on Tamiflu for ue to HD dosing ([MASKED]). She did have infectious work-up for potential superinfection with PNA, but chest imaging was without notable findings. She was briefly on empiric abx and had blood cultures drawn, with no growth at time of discharge. # Anemia of unclear etiology: At baseline, the patient had a hemoglobin of ~9, likely due to ESRD. The patient did not appear malnourished on exam, but of note, nutritional studies had not been performed in several years. As detailed below, there was concern for underlying liver disease in this patient, which could have been contributing to her overall anemia. Additionally, active influenza infection could possibly have caused transient myelosuppression. During this admission, the patient further endorsed black stool (new for several days prior to and during this admission) and was found to be guaiac positive in the FICU. With trending, her hemoglobin did downtrend from her baseline to 7.7 at time of transfer to the general medicine service, concerning for upper GI bleed especially given her prior history of bleeding. She was briefly put on IV PPI and had H.Pylori serologies sent. The patient was found still to be guaiac positive but without melena on rectal exam and her hemoglobin did return to her baseline prior to discharge. The patient was arranged for outpatient follow-up with GI for further evaluation of possible GI bleed. She was also instructed to follow up with her outpatient providers regarding results of her H.Pylori serologies. # Anuric End-Stage Renal Disease s/p DCDRT complicated by allograft failure, re-initiated on HD: The patient has had a history of ESRD since [MASKED], initially on HD. She underwent DCDRT in [MASKED], with subsequent allograft failure and re-initiation on HD in [MASKED]. She has an estimated dry weight of ~66kg and was continued on her home [MASKED] HD schedule. She was also continued on her home calcium supplements and phosphorus binders. She was followed closely by the renal HD service during this admission and discharged home following her last dialysis session on [MASKED] at her dry weight of 66.2kg. # Recurrent C. Diff Colitis: The patient has failed multiple courses of treatment for C diff Colitis and was treated for another episode of recurrent C. Diff during this admission. She was initiated on Vancomycin 125mg PO q6H and Flagyl 500mg IV q8H on [MASKED] while in the ICU and continued on a planned 14 day course of PO Vancomycin. She was discharged home with enough Vancomycin capsules to complete her 14 days course (last dose on [MASKED]. She should also follow up with her PCP and GI about potentially pursuing stool transplant given her multiple relapses. # Atrial Fibrillation: The patient has had a history of poorly controlled afib due to inability to effectively rate control in the setting of intradialytic hypotension. She was rate controlled with fractionated metoprolol equivalent in dosage to her home metoprolol XL 25mg PO daily during this admission. She was continued on ASA 81mg PO daily for stroke prophylaxis during this admission as she has been unable to tolerate systmic anticoagulation in the setting of active and prior GI bleeding as well as prior AV Fistula site bleeding (despite a CHADS2VASC of [MASKED]. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in [MASKED] s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Her CHF was felt to be a major contributor to her overall volume overload, which improved with treatment of her influenza and dialysis. # COPD on Home O2: The patient has PFTs from [MASKED] c/w restrictive lung disease but prior PFTs showing obstructive disease. She was continued on her home inhaler regimen with added duonebs PRN and discharged on her home oxygen regimen of [MASKED] per NC. # Mediastinal Lymphadenopathy: The patient was noted to have mediastinal LAD on chest imaging, likely reactive due to influenza. However, there was concern given poor follow that this could be due to an alternate etiology such as lymphoma or perhaps sarcoidosis. Initial work-up in the hospital was unrevealing with normal LDH and negative ACE levels. Her 1,25 hydroxy Vitamin D levels to evaluate for Sarcoidosis were still pending at time of discharge. She was instructed to follow up with her PCP regarding results of this test and she should had repeat Chest CT to re-evaluate for finding of mediastinal lymphadenopathy. # Thrush: The patient was found to have thrush on exam during this admission, likely due to underlying ESRD as well as use of oral steroid inhalers. She was provided nystatin swish and spit with improvement in her thrush. She also had HIV serologies re-sent, which were still pending at time of discharge. She should follow up with her PCP regarding results of this test. #Hypertension: The patient has history a history of hypertension with blood pressures largely within normal limits during this admission. She did have low blood pressures, likely triggered by dialysis. She responded well to gentle intravenous fluid boluses in the setting of her tenuous respiratory status. She was continued on her fractionated metoprolol and her fluid status was managed with HD as above. Her blood pressures were normal at time of discharge. CHRONIC/STABLE/RESOLVED ISSUES: # Concern for Underlying Liver Disease: The patient was admitted with elevated transaminases and INR as well as history of concern for underlying liver disease. She had CT in [MASKED] showing nodular liver disease and perihepatic ascites. Prior Hep A,B,C studies negative with Hep A/C negative as recently as [MASKED]. The patient had RUQUS this admission, showing signs of congestive hepatopathy suggesting acute contribution from her volume overload. However, cirrhosis could not be ruled out. Her transaminases were monitored closely during this admission and she was treated for her CHF and ESRD as above. With these measures, her liver function tests downtrended prior to admission. She should have further work-up for possible cirrhosis as an outpatient. #GERD: The patient was admitted on oral PPI therapy, which was briefly changed to IV PPI due to concern over active GI bleeding. As above, her H&H stabilized and she was resumed on her home omeprazole prior to discharge. #Breast Cysts: The patient has a history of breast cysts and was continued on her home topical clindamycin throughout this admission. TRANSITIONAL ISSUES: -The patient had >1 point hemoglobin drop with self-reported melena and guaiac positive stool. As her blood counts stabilized prior to discharge, she did not receive further work-up as an inpatient. She should follow-up with GI after discharge for further evaluation. -The patient should have repeat CBC drawn on [MASKED] with results faxed to Dr. [MASKED] (PCP, fax number: [MASKED] -As part of work-up for GI Bleed, the patient had H.Pylori serologies sent during this admission. Results were still pending at time of discharge and the patient should follow up on these with her PCP. -The patient was discharged with instructions to complete 14-day course of Vancomycin 125mg PO q6H for her recurrent C. Diff Colitis (First dose on [MASKED] last dose on [MASKED] -Given the patient's recurrent C Diff Colitis, the patient should be arranged for stool transplant evaluation -The patient should follow up with Dr. [MASKED] (Pulmonology) for management of her Pulmonary Hypertension -The patient received hemodialysis per her home schedule of [MASKED]. Her last HD session was on [MASKED]. -On discharge, the patient's dry weight was 66.2kg -The patient should follow up with her outpatient Nephrologist regarding further management of her ESRD. Given her history of hypotension during dialysis, would consider potentially starting patient on Midodrine or other form of blood pressure support on dialysis days. -During this admission, the patient had elevated LFTs and mild markers of synthetic liver dysfunction. He had RUQ Ultrasound showing likely congestive hepatopathy but cirrhosis was not ruled out. She should have further work-up for cirrhosis as an outpatient. -The patient was found to have incidental finding of mediastinal lymphadenopathy on CTA of the Chest this admission. This should be followed up with repeat CT as an outpatient. Inpatient work-up for possible sarcoidosis was initiated with 1,25-OH Vitamin D levels (pending at time of discharge). This should be followed up with her PCP [MASKED] pulmonologist. -The patient was discharged on her home O2 requirement of [MASKED] liters per nasal cannula -Patient was discharged home on PO nystatin for thrush, likely due to inhaled corticosteroid use -The patient has endorsed leg pain both prior to and during this admission, concerning for possible peripheral vascular disease. She should have formal ABI's to evaluate as an outpatient. -CODE STATUS: FULL CODE -DRY WEIGHT: 66.2kg Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Nephrocaps 1 CAP PO DAILY 3. Calcium Acetate 667 mg PO DAILY 4. Cinacalcet 60 mg PO DAILY 5. Clindamycin 1% Solution 1 Appl TP DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Vancomycin Oral Liquid [MASKED] mg PO Q6H Will need total 14 day course. First day [MASKED] Last day [MASKED]. RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp #*39 Capsule Refills:*0 2. Clindamycin 1% Solution 1 Appl TP DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 5. Nephrocaps 1 CAP PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Refills:*0 7. albuterol sulfate 90 mcg/actuation inhalation Q6H 8. Aspirin 81 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Outpatient Lab Work Please draw repeat CBC on [MASKED] and have results faxed to Dr. [MASKED] at [MASKED]. Diagnosis: Anemia (ICD10: D64.9) 11. Calcium Acetate 667 mg PO TID W/MEALS 12. Omeprazole 40 mg PO DAILY 13. terconazole 0.8 % vaginal QHS:PRN vaginitis Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: -Hypoxia due to Influenza A Infection -Recurrent Clostridium Difficile Colitis -Anemia of unclear etiology -Thrombocytopenia of unclear etiology -End-Stage Renal Disease on Hemodialysis -Diastolic Congestive Heart Failure with Right Heart Failure -Mediastinal Lymphadenopathy without Clear Etiology -Thrush -Congestive Hepatopathy SECONDARY DIAGNOSIS/ES: -Atrial Fibrillation -Chronic Obstructive Pulmonary Disease on Home Oxygen -History of Kidney Transplant with Allograft Nephropathy/Failure -Gastroesophageal Reflux Disease -Hypertension -History of Breast Cysts Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because you were having trouble breathing and were noted to have low blood pressures. You were initially cared for in the intensive care unit (ICU) because your potassium levels were high and needed urgent dialysis. In the ICU, you received 2 sessions of dialysis, which helped your breathing. As you were found to have the flu, you were treated with a medication called Tamiflu. You were also started on an antibiotic to treat your C Diff infection. Upon transferring to the general medicine service, you were found to have slowly decreasing blood counts. As you were having black stools, there was significant concern for an intestinal bleed. With close monitoring, your blood counts stabilized and you were sent home with instructions to follow up with the Gastroenterologists as an outpatient. Prior to discharge, you received 1 more dialysis session and were breathing more comfortably. You had also completed treatment for the flu. It is important that you continue to take your medications and follow up with your outpatient doctors [MASKED] detailed in the rest of your discharge paperwork). It is also very important that you weigh yourself every morning and call your primary care physician if your weight changes by more than 3 lbs. Thank you for allowing us to be a part of your care, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I5032", "D696", "J449", "J45909", "I4891", "K219", "M109" ]
[ "J09X2: Influenza due to identified novel influenza A virus with other respiratory manifestations", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "B370: Candidal stomatitis", "A047: Enterocolitis due to Clostridium difficile", "I5032: Chronic diastolic (congestive) heart failure", "D696: Thrombocytopenia, unspecified", "Z940: Kidney transplant status", "K921: Melena", "Z720: Tobacco use", "R0902: Hypoxemia", "K761: Chronic passive congestion of liver", "Z992: Dependence on renal dialysis", "J449: Chronic obstructive pulmonary disease, unspecified", "J45909: Unspecified asthma, uncomplicated", "I4891: Unspecified atrial fibrillation", "E875: Hyperkalemia", "I953: Hypotension of hemodialysis", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "D631: Anemia in chronic kidney disease", "N6002: Solitary cyst of left breast", "N6001: Solitary cyst of right breast", "R601: Generalized edema" ]
10,055,694
24,232,904
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___ Chief Complaint: Hypotension (SBP in ___ Major Surgical or Invasive Procedure: EGD ___ Capsule endoscopy ___ History of Present Illness: Mrs. ___ is a ___ y/o woman with past history of ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD (___), COPD, GERD (w/out PUD), atrial fibrillation not on coumadin, congestive heart failure and severe right heart failure, pulmonary hypertension, recurrent cdiff infection, upper GI bleed from erosive gastritis and gastric ulcer, chronic anemia, who was transferred from her dialysis center to the ED for hypotension with SBP in ______s. She was recently admitted to ___ in ___ with melena, hypotension, and acute on chronic anemia, and was found to have upper GI bleed from two linear ulcerations in the cardia. On the day of admission, she was found to have hypotension with SBP in ___'s during dialysis, so she was sent to the ED. She reported dark stools for approximately a week, which she attributed to "recurrent C.dif". She denied dizziness, chest pain, shortness of breath, abdominal pain, diarrhea. She noted significant recent distention of her abdomen and some peripheral edema. She denied jaundice in the past. On review of her systems, she admits to shortness of breath and dyspnea on exertion. Patient was recently evaluated in outpatient ___ clinic for new liver disease. She was noted to have an enlarged liver and considered to have congestive hepatopathy. Her most recent liver function tests show an alkaline phosphatase of 162 with a normal ALT and AST of 15 and 24 respectively, negative test for her serum ACE and ___, negative hepatitis B and hepatitis C markers, normal C3 and C4. Rheumatoid factor is increased to 32. She has elevated IgG. Alpha-1 antitrypsin was mildly elevated. An ultrasound of the liver showed dilated inferior vena cava and hepatic veins, consistent with right heart failure. She had trace ascites at that time in ___. Of note, a chest CT from ___ showed innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. In the ED initial vitals: 97.2 82 84/49 18 98% RA Exam was notable for: Gauaic + dark stool - Labs were notable for: WBC 6.3 H/H 7.3/25.3 Platelets 260 ___: 12.8 PTT: 32.6 INR: 1.2 ALT: 10 AP: 171 Tbili: 0.7 Alb: 3.8 AST: 25 LDH: 201 Na 136 K 3.5 Cr 2.3 Ca: 8.8 Mg: 1.8 P: 1.6 Lactate:1.2 Diagnostic para: WBC 733 RBC ___ Poly 5 Lymph 30 Protein 5.0 Glucose 104 Patient was given: Octreotide Acetate 100 mcg IV Q8H Ciprofloxacin 400 mg IV ONCE Pantoprazole 40 mg IV ONCE 2units pRBCs Imaging included CT abdomen and CXR (see below for details) Vitals prior to transfer: 98.9 71 90/47 20 100% RA ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in ___ and treated with flagyl 500mg x 10 days; again in ___ s/p flagyl 500mg x 14 days, persistent infection still later in ___, treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother on dialysis from diabetes mellitus Niece with ESRD, s/p transplant Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VITAL: Afebrile 100/70 80 18 99% RA GENERAL: Well appearing in NAD. HEENT: Exostropia bilaterally, sclera anicteric CARDIAC: Irregular with no excess sounds appreciated LUNGS: Unlabored resp, adequate air movement, prolonged expiratory phase ABDOMEN: soft, distended, non-tender to palpation, hepatomegaly is present EXTREMITIES: Trace pitting edema in ___ bilaterally, warm and well perfused, tender to palpation NEUROLOGY: No asterixis, no sensory or motor deficits noted PHYSICAL EXAM ON DISCHARGE: =========================== VS: 98.7 85 111/57 18 97 RA GENERAL: NAD, pleasant, sitting comfortably in chair HEENT: OP clear, anicteric sclera, apparent proptosis and exotropia, pale conjunctiva CARDS: Irregularrly irregular, no murmurs, rubs, gallops PULM: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, mild epigastric tenderness, mild distension but soft, normoactive bowel sounds, no organomegaly EXTREMITIES: Warm, no edema ACCESS: LUE AVG; good thrill/bruits heard NEURO: No asterixis Pertinent Results: LAB RESULTS ON ADMISSION: ========================= ___ 10:45AM BLOOD WBC-6.3 RBC-2.40* Hgb-7.3* Hct-25.3* MCV-105* MCH-30.4 MCHC-28.9* RDW-20.8* RDWSD-78.9* Plt ___ ___ 10:45AM BLOOD ___ PTT-32.6 ___ ___ 10:45AM BLOOD Glucose-89 UreaN-14 Creat-2.3*# Na-136 K-3.5 Cl-95* HCO3-30 AnGap-15 ___ 10:45AM BLOOD ALT-10 AST-25 LD(LDH)-201 AlkPhos-171* TotBili-0.7 ___ 10:45AM BLOOD Albumin-3.8 Calcium-8.8 Phos-1.6* Mg-1.8 ___ 06:30PM BLOOD Hgb-8.6* calcHCT-26 ___ 12:00PM ASCITES WBC-733* ___ Polys-5* Lymphs-30* ___ Mesothe-6* Macroph-59* Other-0 ___ 12:00PM ASCITES TotPro-5.0 Glucose-104 PERTINENT INTERVAL LABS: ======================== ___ 06:08AM BLOOD CA125-276* ___ 03:10PM ASCITES TotPro-5.2 Albumin-2.5 ___ 05:47AM BLOOD Albumin-3.6 Calcium-8.6 Phos-6.6* Mg-1.9 ___ 13:11 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 1850 H 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 3 74 ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 4 359 H ___ mg/dL IMMUNOGLOBULIN G, SERUM 2402 H ___ mg/dL LAB RESULTS ON DISCHARGE: ========================= ___ 06:08AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.2* Hct-28.6* MCV-105* MCH-30.0 MCHC-28.7* RDW-20.1* RDWSD-76.2* Plt ___ ___ 06:08AM BLOOD ___ PTT-31.7 ___ ___ 06:08AM BLOOD Glucose-140* UreaN-12 Creat-3.8* Na-136 K-3.6 Cl-94* HCO3-32 AnGap-14 ___ 06:08AM BLOOD ALT-7 AST-14 AlkPhos-124* TotBili-0.8 ___ 06:08AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.8 Mg-1.7 RADIOLOGY: ========== ___ CT ABDOMEN/PELVIS: 1. Abnormal soft tissue prominence in the bilateral adnexa, right-greater-than-left. Recommend correlation with prior clinical history (including prior fallopian tube exploration?) and cytology results from recent paracentesis. If results are nondiagnostic, an MRI of the pelvis with IV contrast should be considered to exclude underlying malignancy, especially in light of enlarged retroperitoneal lymph nodes. 2. Cirrhotic liver morphology. 3. Moderate amount of nonhemorrhagic ascites. 4. Prominent intramural fat in the cecum and ascending ___, ___ reflect chronic inflammation. 5. Right lower quadrant transplanted kidney is abnormal in appearance ; atrophic with loss of normal corticomedullary differentiation. 6. Renal osteodystrophy. RECOMMENDATION(S): Correlation with clinical history and cytology results. Consider pelvis MRI for further evaluation. ___ CXR: -------------- Mild pulmonary edema. No focal consolidation. PATHOLOGY: ========== ___ CYTOLOGY, ASCITIC FLUID NEGATIVE FOR MALIGNANT CELLS. - Predominantly blood with scattered admixed mesothelial cells and lymphocytes. GI ENDOSCOPY: ============= ___ EGD -------------- Large hiatal hernia was noted Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs. ___ is a ___ y/o woman with complicated past history most notable for severe right heart failure, pulmonary hypertension, upper GI bleed from erosive gastritis and gastric ulcer and ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD (___), who was transferred from her dialysis center to the ED for hypotension with SBP in ___ in setting of melena. CT abdomen/pelvis performed in ED is notable for abnormal soft tissue prominence in bilateral adnexa, R>L; cytology of ascitic fluid negative for malignancy, and diagnostic paracentesis was negative for SBP. ___ EGD only notable for hiatal hernia, no bleed. She had an additional episode of melena on ___ and the decision was made to proceed with capsule endoscopy on ___. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable. We planned to do an echocardiogram during this admission to reassess her right heart failure, but we were unable to get this study done and she was eager to be discharged. She received 2 U pRBC throughout stay; discharge Hgb was 8.2; she was hemodynamically stable. # Hypotension/ acute on chronic anemia/ melena: One week history of melena prior to presentation, in context of recent admission for upper GI bleed with endoscopy showing linear gastric ulcer as well as erosive gastritis as well as prior history of recurrent C.diff. She was initially treated with IV pantoprazole q12H, octreotide gtt, and ciprofloxacin 400 mg IV q24H due to concern for UGIB. ___ EGD only notable for hiatal hernia, no bleed; hence octreotide was discontinued at that time. She had an additional episode of melena on ___ and the decision was made to proceed with capsule endoscopy on ___. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable; 8.2 on discharge. # Ascites: CT abdomen notable for cirrhotic liver morphology, moderate ascites, and abnormal soft tissue prominence in bilateral adnexa, R>L. She has had prior work up with negative hepatitis B and C serologies, no alpha 1 antitrypsin deficiency, normal C3, C4, ___. Differential diagnosis for her includes cardiac cirrhosis given elevated protein at 5 (>2.5) and her history of R heart failure which would be consistent with elevated SAAG of 1.1 on ___. Meig's syndrome/malignancy is also under consideration given the fullness in adnexa and ascites, in setting of an elevated CA 125. Cytology negative for malignant cells. Typically would consider MRI pelvis with contrast to further evaluate however patient is very claustrophobic; please discuss further work up as an outpatient. # Elevated IgG: IgG was recently found to be elevated to 2455, raising concerns for plasma cell disorders, leukemia, and lymphoma among other disease, especially with abnormal findings on CT chest and abdomen. IgG 1 and 4 ___s total IgG were found to be elevated on the sub-type analysis. Please consider immunology referral # Anuric End-Stage Renal Disease s/p cadaveric donor renal transplant complicated by allograft failure, re-initiated on HD ___. - Continue dialysis per renal team # Atrial Fibrillation: CHADS2-VASC score 3, not currently on anticoagulation given history of GI and AV fistula bleed. Home metoprolol was held due to concern for hypotension. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in ___ ___s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Patient mildly volume up on exam, but saturating well on home O2 requirement. We had planned on obtaining a repeat echocardiogram, however this was not done and patient was eager to leave. Home metoprolol was held due to concern for hypotension. # Chronic obstructive pulmonary disease: Patient last had pulmonary function testing in ___, which showed moderately reduced FVC, moderately severe reduction in FEV1, with elevated FEV1/FVC, thought to reflect moderately severe obstructive disease. She was continued on home albuterol neb Q4H as needed and advair (250/50) twice a day # GERD: Patient takes PO omeprazole 40mg QD at home, which was switched to IV pantoprazole 40mg BID in setting of melena TRANSITIONAL ISSUES =================== [ ] Findings of new ascites and adnexal fullness on CT are concerning for malignancy especially in setting of elevated CA 125 to 276 (though it is noted that CA 125 is nonspecific and shouldn't be used as screening test for ovarian cancer). Cytology negative. Please consider MRI to further evaluate, though patient reports she is extremely claustrophobic. [ ] Capsule study results are pending at the time of discharge. Please follow up and refer to outpatient GI or book further testing/procedures as needed. Hgb on discharge is 8.2 [ ] Consider outpatient echocardiogram given new ascites, known right heart failure and last echo ___. [ ] Given recent finding of elevated total IgG on testing sent by outpatient hepatology, IgG subclasses were sent and revealed elevated IgG1 and IgG 4. Further workup per outpatient hepatology. # Code: Full # Communication: ___ (sister and HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 6. Nephrocaps 1 CAP PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 4 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 2. albuterol sulfate 90 mcg/actuation inhalation Q6H 3. Aspirin 81 mg PO DAILY 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. Pantoprazole 40 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Secondary: Congestive heart failure, ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because your blood pressure was low. As you were recently in the hospital because of a bleeding ulcer in your stomach, we wanted to make sure that you are no longer bleeding. Therefore we did a upper endoscopy, which did not show any bleeding. However, you had some more dark stools and your blood counts dropped. Hence we gave you blood, and did a capsule endoscopy, which can look further for sources of bleeding. A very preliminary look at the study did not show any active bleeding, but showed some possible culprits in the first part of your small intestine. The full report will be done soon and should be available to your PCP at your follow up appointment. We also noticed that your belly was very distended with fluid. This can happen for many reasons- for instance, right sided heart failure (which you have a history of) causing liver problems, a sick liver, or cancer. We took some of the fluid out to both take a closer look and to make you feel better. We also did a CT scan, and obtained an ultrasound of your heart (Echo). The CT scan showed that you have some fullness in your adnexa (where your ovaries and tubes are), and we are waiting for the results of the fluid we sent out to look for cancer. We also planned to check an echocardiogram (an ultrasound of your heart). Unfortunately, we were not able to get this study done for you while you were here. This can be ordered by your PCP or your cardiologist and done as an outpatient. Please follow up with your primary care doctor this week. Please also follow up with your liver doctor, ___ in the next few weeks. Best wishes, Your ___ Team Followup Instructions: ___
[ "K922", "N186", "T8612", "I120", "I5032", "I272", "D62", "I4891", "Z992", "K449", "J449", "K219", "F329", "Z7982", "F17210", "Z9981" ]
Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Chief Complaint: Hypotension (SBP in [MASKED] Major Surgical or Invasive Procedure: EGD [MASKED] Capsule endoscopy [MASKED] History of Present Illness: Mrs. [MASKED] is a [MASKED] y/o woman with past history of ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD ([MASKED]), COPD, GERD (w/out PUD), atrial fibrillation not on coumadin, congestive heart failure and severe right heart failure, pulmonary hypertension, recurrent cdiff infection, upper GI bleed from erosive gastritis and gastric ulcer, chronic anemia, who was transferred from her dialysis center to the ED for hypotension with SBP in s. She was recently admitted to [MASKED] in [MASKED] with melena, hypotension, and acute on chronic anemia, and was found to have upper GI bleed from two linear ulcerations in the cardia. On the day of admission, she was found to have hypotension with SBP in [MASKED]'s during dialysis, so she was sent to the ED. She reported dark stools for approximately a week, which she attributed to "recurrent C.dif". She denied dizziness, chest pain, shortness of breath, abdominal pain, diarrhea. She noted significant recent distention of her abdomen and some peripheral edema. She denied jaundice in the past. On review of her systems, she admits to shortness of breath and dyspnea on exertion. Patient was recently evaluated in outpatient [MASKED] clinic for new liver disease. She was noted to have an enlarged liver and considered to have congestive hepatopathy. Her most recent liver function tests show an alkaline phosphatase of 162 with a normal ALT and AST of 15 and 24 respectively, negative test for her serum ACE and [MASKED], negative hepatitis B and hepatitis C markers, normal C3 and C4. Rheumatoid factor is increased to 32. She has elevated IgG. Alpha-1 antitrypsin was mildly elevated. An ultrasound of the liver showed dilated inferior vena cava and hepatic veins, consistent with right heart failure. She had trace ascites at that time in [MASKED]. Of note, a chest CT from [MASKED] showed innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. In the ED initial vitals: 97.2 82 84/49 18 98% RA Exam was notable for: Gauaic + dark stool - Labs were notable for: WBC 6.3 H/H 7.3/25.3 Platelets 260 [MASKED]: 12.8 PTT: 32.6 INR: 1.2 ALT: 10 AP: 171 Tbili: 0.7 Alb: 3.8 AST: 25 LDH: 201 Na 136 K 3.5 Cr 2.3 Ca: 8.8 Mg: 1.8 P: 1.6 Lactate:1.2 Diagnostic para: WBC 733 RBC [MASKED] Poly 5 Lymph 30 Protein 5.0 Glucose 104 Patient was given: Octreotide Acetate 100 mcg IV Q8H Ciprofloxacin 400 mg IV ONCE Pantoprazole 40 mg IV ONCE 2units pRBCs Imaging included CT abdomen and CXR (see below for details) Vitals prior to transfer: 98.9 71 90/47 20 100% RA ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD [MASKED]. s/p DCDKD in [MASKED] c/b chronic allograft nephropathy in [MASKED] with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on [MASKED] home oxygen; FEV1 of 57% predicted [MASKED] - Diastolic CHF - Last TTE in [MASKED] with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in [MASKED] and treated with flagyl 500mg x 10 days; again in [MASKED] s/p flagyl 500mg x 14 days, persistent infection still later in [MASKED], treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy [MASKED] - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: [MASKED] Family History: Mother on dialysis from diabetes mellitus Niece with ESRD, s/p transplant Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VITAL: Afebrile 100/70 80 18 99% RA GENERAL: Well appearing in NAD. HEENT: Exostropia bilaterally, sclera anicteric CARDIAC: Irregular with no excess sounds appreciated LUNGS: Unlabored resp, adequate air movement, prolonged expiratory phase ABDOMEN: soft, distended, non-tender to palpation, hepatomegaly is present EXTREMITIES: Trace pitting edema in [MASKED] bilaterally, warm and well perfused, tender to palpation NEUROLOGY: No asterixis, no sensory or motor deficits noted PHYSICAL EXAM ON DISCHARGE: =========================== VS: 98.7 85 111/57 18 97 RA GENERAL: NAD, pleasant, sitting comfortably in chair HEENT: OP clear, anicteric sclera, apparent proptosis and exotropia, pale conjunctiva CARDS: Irregularrly irregular, no murmurs, rubs, gallops PULM: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, mild epigastric tenderness, mild distension but soft, normoactive bowel sounds, no organomegaly EXTREMITIES: Warm, no edema ACCESS: LUE AVG; good thrill/bruits heard NEURO: No asterixis Pertinent Results: LAB RESULTS ON ADMISSION: ========================= [MASKED] 10:45AM BLOOD WBC-6.3 RBC-2.40* Hgb-7.3* Hct-25.3* MCV-105* MCH-30.4 MCHC-28.9* RDW-20.8* RDWSD-78.9* Plt [MASKED] [MASKED] 10:45AM BLOOD [MASKED] PTT-32.6 [MASKED] [MASKED] 10:45AM BLOOD Glucose-89 UreaN-14 Creat-2.3*# Na-136 K-3.5 Cl-95* HCO3-30 AnGap-15 [MASKED] 10:45AM BLOOD ALT-10 AST-25 LD(LDH)-201 AlkPhos-171* TotBili-0.7 [MASKED] 10:45AM BLOOD Albumin-3.8 Calcium-8.8 Phos-1.6* Mg-1.8 [MASKED] 06:30PM BLOOD Hgb-8.6* calcHCT-26 [MASKED] 12:00PM ASCITES WBC-733* [MASKED] Polys-5* Lymphs-30* [MASKED] Mesothe-6* Macroph-59* Other-0 [MASKED] 12:00PM ASCITES TotPro-5.0 Glucose-104 PERTINENT INTERVAL LABS: ======================== [MASKED] 06:08AM BLOOD CA125-276* [MASKED] 03:10PM ASCITES TotPro-5.2 Albumin-2.5 [MASKED] 05:47AM BLOOD Albumin-3.6 Calcium-8.6 Phos-6.6* Mg-1.9 [MASKED] 13:11 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 1850 H 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 [MASKED] mg/dL IMMUNOGLOBULIN G SUBCLASS 3 74 [MASKED] mg/dL IMMUNOGLOBULIN G SUBCLASS 4 359 H [MASKED] mg/dL IMMUNOGLOBULIN G, SERUM 2402 H [MASKED] mg/dL LAB RESULTS ON DISCHARGE: ========================= [MASKED] 06:08AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.2* Hct-28.6* MCV-105* MCH-30.0 MCHC-28.7* RDW-20.1* RDWSD-76.2* Plt [MASKED] [MASKED] 06:08AM BLOOD [MASKED] PTT-31.7 [MASKED] [MASKED] 06:08AM BLOOD Glucose-140* UreaN-12 Creat-3.8* Na-136 K-3.6 Cl-94* HCO3-32 AnGap-14 [MASKED] 06:08AM BLOOD ALT-7 AST-14 AlkPhos-124* TotBili-0.8 [MASKED] 06:08AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.8 Mg-1.7 RADIOLOGY: ========== [MASKED] CT ABDOMEN/PELVIS: 1. Abnormal soft tissue prominence in the bilateral adnexa, right-greater-than-left. Recommend correlation with prior clinical history (including prior fallopian tube exploration?) and cytology results from recent paracentesis. If results are nondiagnostic, an MRI of the pelvis with IV contrast should be considered to exclude underlying malignancy, especially in light of enlarged retroperitoneal lymph nodes. 2. Cirrhotic liver morphology. 3. Moderate amount of nonhemorrhagic ascites. 4. Prominent intramural fat in the cecum and ascending [MASKED], [MASKED] reflect chronic inflammation. 5. Right lower quadrant transplanted kidney is abnormal in appearance ; atrophic with loss of normal corticomedullary differentiation. 6. Renal osteodystrophy. RECOMMENDATION(S): Correlation with clinical history and cytology results. Consider pelvis MRI for further evaluation. [MASKED] CXR: -------------- Mild pulmonary edema. No focal consolidation. PATHOLOGY: ========== [MASKED] CYTOLOGY, ASCITIC FLUID NEGATIVE FOR MALIGNANT CELLS. - Predominantly blood with scattered admixed mesothelial cells and lymphocytes. GI ENDOSCOPY: ============= [MASKED] EGD -------------- Large hiatal hernia was noted Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs. [MASKED] is a [MASKED] y/o woman with complicated past history most notable for severe right heart failure, pulmonary hypertension, upper GI bleed from erosive gastritis and gastric ulcer and ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD ([MASKED]), who was transferred from her dialysis center to the ED for hypotension with SBP in [MASKED] in setting of melena. CT abdomen/pelvis performed in ED is notable for abnormal soft tissue prominence in bilateral adnexa, R>L; cytology of ascitic fluid negative for malignancy, and diagnostic paracentesis was negative for SBP. [MASKED] EGD only notable for hiatal hernia, no bleed. She had an additional episode of melena on [MASKED] and the decision was made to proceed with capsule endoscopy on [MASKED]. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable. We planned to do an echocardiogram during this admission to reassess her right heart failure, but we were unable to get this study done and she was eager to be discharged. She received 2 U pRBC throughout stay; discharge Hgb was 8.2; she was hemodynamically stable. # Hypotension/ acute on chronic anemia/ melena: One week history of melena prior to presentation, in context of recent admission for upper GI bleed with endoscopy showing linear gastric ulcer as well as erosive gastritis as well as prior history of recurrent C.diff. She was initially treated with IV pantoprazole q12H, octreotide gtt, and ciprofloxacin 400 mg IV q24H due to concern for UGIB. [MASKED] EGD only notable for hiatal hernia, no bleed; hence octreotide was discontinued at that time. She had an additional episode of melena on [MASKED] and the decision was made to proceed with capsule endoscopy on [MASKED]. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable; 8.2 on discharge. # Ascites: CT abdomen notable for cirrhotic liver morphology, moderate ascites, and abnormal soft tissue prominence in bilateral adnexa, R>L. She has had prior work up with negative hepatitis B and C serologies, no alpha 1 antitrypsin deficiency, normal C3, C4, [MASKED]. Differential diagnosis for her includes cardiac cirrhosis given elevated protein at 5 (>2.5) and her history of R heart failure which would be consistent with elevated SAAG of 1.1 on [MASKED]. Meig's syndrome/malignancy is also under consideration given the fullness in adnexa and ascites, in setting of an elevated CA 125. Cytology negative for malignant cells. Typically would consider MRI pelvis with contrast to further evaluate however patient is very claustrophobic; please discuss further work up as an outpatient. # Elevated IgG: IgG was recently found to be elevated to 2455, raising concerns for plasma cell disorders, leukemia, and lymphoma among other disease, especially with abnormal findings on CT chest and abdomen. IgG 1 and 4 s total IgG were found to be elevated on the sub-type analysis. Please consider immunology referral # Anuric End-Stage Renal Disease s/p cadaveric donor renal transplant complicated by allograft failure, re-initiated on HD [MASKED]. - Continue dialysis per renal team # Atrial Fibrillation: CHADS2-VASC score 3, not currently on anticoagulation given history of GI and AV fistula bleed. Home metoprolol was held due to concern for hypotension. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in [MASKED] s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Patient mildly volume up on exam, but saturating well on home O2 requirement. We had planned on obtaining a repeat echocardiogram, however this was not done and patient was eager to leave. Home metoprolol was held due to concern for hypotension. # Chronic obstructive pulmonary disease: Patient last had pulmonary function testing in [MASKED], which showed moderately reduced FVC, moderately severe reduction in FEV1, with elevated FEV1/FVC, thought to reflect moderately severe obstructive disease. She was continued on home albuterol neb Q4H as needed and advair (250/50) twice a day # GERD: Patient takes PO omeprazole 40mg QD at home, which was switched to IV pantoprazole 40mg BID in setting of melena TRANSITIONAL ISSUES =================== [ ] Findings of new ascites and adnexal fullness on CT are concerning for malignancy especially in setting of elevated CA 125 to 276 (though it is noted that CA 125 is nonspecific and shouldn't be used as screening test for ovarian cancer). Cytology negative. Please consider MRI to further evaluate, though patient reports she is extremely claustrophobic. [ ] Capsule study results are pending at the time of discharge. Please follow up and refer to outpatient GI or book further testing/procedures as needed. Hgb on discharge is 8.2 [ ] Consider outpatient echocardiogram given new ascites, known right heart failure and last echo [MASKED]. [ ] Given recent finding of elevated total IgG on testing sent by outpatient hepatology, IgG subclasses were sent and revealed elevated IgG1 and IgG 4. Further workup per outpatient hepatology. # Code: Full # Communication: [MASKED] (sister and HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 6. Nephrocaps 1 CAP PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 4 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 2. albuterol sulfate 90 mcg/actuation inhalation Q6H 3. Aspirin 81 mg PO DAILY 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK ([MASKED]) 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. Pantoprazole 40 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Secondary: Congestive heart failure, ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because your blood pressure was low. As you were recently in the hospital because of a bleeding ulcer in your stomach, we wanted to make sure that you are no longer bleeding. Therefore we did a upper endoscopy, which did not show any bleeding. However, you had some more dark stools and your blood counts dropped. Hence we gave you blood, and did a capsule endoscopy, which can look further for sources of bleeding. A very preliminary look at the study did not show any active bleeding, but showed some possible culprits in the first part of your small intestine. The full report will be done soon and should be available to your PCP at your follow up appointment. We also noticed that your belly was very distended with fluid. This can happen for many reasons- for instance, right sided heart failure (which you have a history of) causing liver problems, a sick liver, or cancer. We took some of the fluid out to both take a closer look and to make you feel better. We also did a CT scan, and obtained an ultrasound of your heart (Echo). The CT scan showed that you have some fullness in your adnexa (where your ovaries and tubes are), and we are waiting for the results of the fluid we sent out to look for cancer. We also planned to check an echocardiogram (an ultrasound of your heart). Unfortunately, we were not able to get this study done for you while you were here. This can be ordered by your PCP or your cardiologist and done as an outpatient. Please follow up with your primary care doctor this week. Please also follow up with your liver doctor, [MASKED] in the next few weeks. Best wishes, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I5032", "D62", "I4891", "J449", "K219", "F329", "F17210" ]
[ "K922: Gastrointestinal hemorrhage, unspecified", "N186: End stage renal disease", "T8612: Kidney transplant failure", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "I272: Other secondary pulmonary hypertension", "D62: Acute posthemorrhagic anemia", "I4891: Unspecified atrial fibrillation", "Z992: Dependence on renal dialysis", "K449: Diaphragmatic hernia without obstruction or gangrene", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "Z7982: Long term (current) use of aspirin", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z9981: Dependence on supplemental oxygen" ]
10,055,694
26,271,755
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors / lisinopril Attending: ___. Chief Complaint: fistula ulceration Major Surgical or Invasive Procedure: AV Fistula Revision ___ ___ guided paracentesis ___ History of Present Illness: ___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presents with ulceration over her AV fistula. Patient notes that the ulcer developed one week ago after she had removed tape from the site of ulcer (note: she reports that she normally applies cream to the fistula site and covers it with tape). Ulceration then noticed by outpatient HD RN two days ago and advised patient to come in, however patient refused at that time. This morning, she went to dialysis, who referred her here as they were unable to access her HD site. Her last HD session was ___. She reports that the ulceration has been present for approximately one week and that she has been applying lidocaine-prilocaine cream to the area. It is pruritic. She denies purulence, erythema, or discharge. No fevers, chills, chest pain, shortness of breath. In the ED, initial vital signs were: T98 HR94 BP101/53 RR 15 SaO2 95% Nasal Cannula - Exam notable for: L arm fistula w/ palpable thrill, ~1 cm healed ulceration with mild tenderness, no erythema or discharge, RRR, scattered wheezes bilaterally, breathing comfortably, abdomen distended, tense, non-tender, 1+ edema bilaterally. - Labs were notable for Cr 5.9, Hgb 9.2, WBC 6.3, AP 231, LFTs normal, Albumin 3.3, INR 1.3. - Studies performed include CXR (demonstrated pulmonary vascular congestion, diffuse bilateral interstitial edema, small right pleural effusion, bilateral linear atelectasis) - Patient was given midodrine, calcium acetate, gabapentin 100 mg, albuterol neb, diskus, Tylenol. She had an HD session prior to arriving on the floor. - Vitals on transfer: 98.1, 91/50, 80, 20, 98% 3L Upon arrival to the floor, the patient was hungry and wanted to eat. Also endorsed pain and numbness in her right foot, which she often has after dialysis. Denies abdominal pain REVIEW OF SYSTEMS: (+) per HPI (-) otherwise Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - H/O syphilis - H/O Breast Cysts - PELVIC MASS - ASCITES - Cryptogenic CIRRHOSIS PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: She denies a family history of liver disease. Family history of father with atherosclerotic CVD. Mother with diabetes on dialysis. No history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.1, 91/50, 80, 20, 98% 3L GENERAL: AOx3, NAD HEENT: Scleral icterus, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: Coarse crackles in left lower lung fields, otherwise clear to auscultation ABDOMEN: Distended tense abdomen, dull to percussion, +shifting dullness, nontender to palpation EXTREMITIES: 1+ lower extremity edema, pitting to mid-shins SKIN: LUE fistula with 2cm area of ulceration without active pus or overlying erythema NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: VS: 98.3, 94/58, 76, 20, 100% RA GENERAL: AOx3, NAD HEENT: Scleral icterus, significant exotropia OD, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: breathing nonlabored, CTA anteriorly ABDOMEN: Distended abdomen, dull to percussion, somewhat tense, nontender, hypoactive BS EXTREMITIES: WWP, no extremity edema SKIN: LUE fistula with surgical dressing c/d/i NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS: --------------- ___ 08:05AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.2* Hct-30.5* MCV-94 MCH-28.4 MCHC-30.2* RDW-19.5* RDWSD-66.9* Plt ___ ___ 08:05AM BLOOD Neuts-61.6 ___ Monos-12.7 Eos-3.0 Baso-0.8 Im ___ AbsNeut-3.87 AbsLymp-1.36 AbsMono-0.80 AbsEos-0.19 AbsBaso-0.05 ___ 08:05AM BLOOD ___ PTT-36.5 ___ ___ 08:05AM BLOOD Plt ___ ___ 08:05AM BLOOD Glucose-111* UreaN-41* Creat-5.9* Na-139 K-4.2 Cl-98 HCO3-27 AnGap-18 ___ 08:05AM BLOOD ALT-11 AST-21 LD(LDH)-145 AlkPhos-231* TotBili-0.8 ___ 08:05AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.1 Mg-1.9 DISCHARGE LABS: ---------------- ___ 09:35AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.0* Hct-30.4* MCV-94 MCH-27.9 MCHC-29.6* RDW-19.5* RDWSD-65.1* Plt ___ ___ 09:35AM BLOOD Plt ___ ___ 09:35AM BLOOD Glucose-97 UreaN-32* Creat-6.1*# Na-135 K-5.0 Cl-93* HCO3-31 AnGap-16 ___ 09:35AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 IMAGING: --------- CXR ___ 1. Mild-to-moderate pulmonary vascular congestion, diffuse bilateral interstitial edema, and trace right pleural effusion suggest volume overload. 2. Bilateral linear atelectasis. PARACENTESIS ___ Technically successful ultrasound-guided therapeutic paracentesis, yielding 4 L of clear, straw-colored ascitic fluid. Brief Hospital Course: ___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presenting with ulceration over her AV fistula. # AVF ulceration: New ulceration on site of AVF, perhaps from patient self-applying tape over the fistula. Underwent fistula revision ___. # ESRD s/p ECD kidney transplant in ___ c/b chronic allograft nephropathy: Chronic focal segmental glomerulosclerosis. Was on dialysis from ___. Had a transplant in ___, but failed in ___. Resumed dialysis in ___, MWF with LUE AVF. Continued home medications. Had session of HD ___ prior to discharge without complications. Resume MWF schedule. # Anemia: Likely from low epo and anemia of chronic disease. Continued Epo 60,000U qHD # Cryptogenic cirrhosis: Perhaps cardiac cirrhosis in setting of right-sided heart failure. Complicated by portal hypertension with ascites and splenomegaly. Up to date on variceal and HCC screening based on most recent Hepatology note. Last EGD ___ found large hiatal hernia. Has q2 week paracentesis, due again on ___. Received ___ guided paracentesis on ___ with 4L fluid removed. #Concern for gyn malignancy: Concern for ovarian or other malignancy as a cause of ascites, elevated CA-125 (276 on ___. Patient was offered MRI as an inpatient (both sedated or regular with premedication) but declined despite counseling of the risks. She reports that she did not want to be out of it with breathing support but also could not be enclosed. She raised the idea of an open MRI and discussed that image quality is not as good but patient was adamant. Primary care doctor was contacted regarding open MRI. # Aflutter # Afib: Was previously on Coumadin and carvedilol. The Coumadin was stopped in ___ secondary to frequent fistula bleeding events. It was restarted in ___. Risk of hemorrhagic stroke is higher with warfarin use in ___ HD patients. No current anticoagulation. # COPD: On 3L home O2 since ___. Continued home management. # Chronic diastolic heart failure # Pulmonary hypertension: Seen by cardiology in ___. Not on any cardiac meds due to hypotension. Unable to aggressively remove fluid with UF due to hypotension as well. # GERD: Continued home pantoprazole TRANSITIONAL ISSUES: - Patient needs open MRI to evaluate for possible malignancy #Code Status: Presumed full code #Emergency Contact/HCP: ___ (___), alternate contact is ___, sister (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Nephrocaps 1 CAP PO DAILY 5. Calcium Acetate 667 mg PO TID W/MEALS 6. Pantoprazole 40 mg PO Q24H 7. HydrOXYzine 25 mg PO Q4H:PRN pruritis Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. HydrOXYzine 25 mg PO Q4H:PRN pruritis 6. Nephrocaps 1 CAP PO DAILY 7. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: AV Fistula Ulceration ESRD on HD Cryptogenic cirrhosis COPD on home O2 atrial fibrillation/flutter portal hypertension with ascites and splenomegaly chronic diastolic heart failure pulmonary hypertension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had a problem with your fistula. It was fixed in a procedure called a fistula revision. You had a dialysis session on ___ that went well so you can continue your regular dialysis schedule. You had a lot of fluid in your abdomen that was removed by our radiology team. You need an MRI of your abdomen to help figure out why you have all of this fluid building up. You were offered this test while you were here but you felt claustrophobic and you did not want to be sedated either. Instead you were hoping to have an open MRI. Please talk to your primary care doctor about scheduling this important test. Please see your follow-up appointments below. It was a pleasure caring for you and we wish you the best, Your ___ Team Followup Instructions: ___
[ "T82898A", "N186", "I132", "T8612", "R188", "K766", "I272", "I5032", "I4892", "L98499", "D631", "D638", "F17210", "Z23", "Z992", "J449", "Z9981", "R234", "R161", "I4891", "K219", "K7469", "K449", "F40240", "F329", "Y832", "Y830", "Y929" ]
Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors / lisinopril Chief Complaint: fistula ulceration Major Surgical or Invasive Procedure: AV Fistula Revision [MASKED] [MASKED] guided paracentesis [MASKED] History of Present Illness: [MASKED] w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presents with ulceration over her AV fistula. Patient notes that the ulcer developed one week ago after she had removed tape from the site of ulcer (note: she reports that she normally applies cream to the fistula site and covers it with tape). Ulceration then noticed by outpatient HD RN two days ago and advised patient to come in, however patient refused at that time. This morning, she went to dialysis, who referred her here as they were unable to access her HD site. Her last HD session was [MASKED]. She reports that the ulceration has been present for approximately one week and that she has been applying lidocaine-prilocaine cream to the area. It is pruritic. She denies purulence, erythema, or discharge. No fevers, chills, chest pain, shortness of breath. In the ED, initial vital signs were: T98 HR94 BP101/53 RR 15 SaO2 95% Nasal Cannula - Exam notable for: L arm fistula w/ palpable thrill, ~1 cm healed ulceration with mild tenderness, no erythema or discharge, RRR, scattered wheezes bilaterally, breathing comfortably, abdomen distended, tense, non-tender, 1+ edema bilaterally. - Labs were notable for Cr 5.9, Hgb 9.2, WBC 6.3, AP 231, LFTs normal, Albumin 3.3, INR 1.3. - Studies performed include CXR (demonstrated pulmonary vascular congestion, diffuse bilateral interstitial edema, small right pleural effusion, bilateral linear atelectasis) - Patient was given midodrine, calcium acetate, gabapentin 100 mg, albuterol neb, diskus, Tylenol. She had an HD session prior to arriving on the floor. - Vitals on transfer: 98.1, 91/50, 80, 20, 98% 3L Upon arrival to the floor, the patient was hungry and wanted to eat. Also endorsed pain and numbness in her right foot, which she often has after dialysis. Denies abdominal pain REVIEW OF SYSTEMS: (+) per HPI (-) otherwise Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD [MASKED]. s/p DCDKD in [MASKED] c/b chronic allograft nephropathy in [MASKED] with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on [MASKED] home oxygen; FEV1 of 57% predicted [MASKED] - Diastolic CHF - Last TTE in [MASKED] with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - H/O syphilis - H/O Breast Cysts - PELVIC MASS - ASCITES - Cryptogenic CIRRHOSIS PAST SURGICAL HISTORY: - Open cholecystectomy [MASKED] - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: [MASKED] Family History: She denies a family history of liver disease. Family history of father with atherosclerotic CVD. Mother with diabetes on dialysis. No history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.1, 91/50, 80, 20, 98% 3L GENERAL: AOx3, NAD HEENT: Scleral icterus, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: Coarse crackles in left lower lung fields, otherwise clear to auscultation ABDOMEN: Distended tense abdomen, dull to percussion, +shifting dullness, nontender to palpation EXTREMITIES: 1+ lower extremity edema, pitting to mid-shins SKIN: LUE fistula with 2cm area of ulceration without active pus or overlying erythema NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: VS: 98.3, 94/58, 76, 20, 100% RA GENERAL: AOx3, NAD HEENT: Scleral icterus, significant exotropia OD, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: breathing nonlabored, CTA anteriorly ABDOMEN: Distended abdomen, dull to percussion, somewhat tense, nontender, hypoactive BS EXTREMITIES: WWP, no extremity edema SKIN: LUE fistula with surgical dressing c/d/i NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS: --------------- [MASKED] 08:05AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.2* Hct-30.5* MCV-94 MCH-28.4 MCHC-30.2* RDW-19.5* RDWSD-66.9* Plt [MASKED] [MASKED] 08:05AM BLOOD Neuts-61.6 [MASKED] Monos-12.7 Eos-3.0 Baso-0.8 Im [MASKED] AbsNeut-3.87 AbsLymp-1.36 AbsMono-0.80 AbsEos-0.19 AbsBaso-0.05 [MASKED] 08:05AM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 08:05AM BLOOD Plt [MASKED] [MASKED] 08:05AM BLOOD Glucose-111* UreaN-41* Creat-5.9* Na-139 K-4.2 Cl-98 HCO3-27 AnGap-18 [MASKED] 08:05AM BLOOD ALT-11 AST-21 LD(LDH)-145 AlkPhos-231* TotBili-0.8 [MASKED] 08:05AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.1 Mg-1.9 DISCHARGE LABS: ---------------- [MASKED] 09:35AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.0* Hct-30.4* MCV-94 MCH-27.9 MCHC-29.6* RDW-19.5* RDWSD-65.1* Plt [MASKED] [MASKED] 09:35AM BLOOD Plt [MASKED] [MASKED] 09:35AM BLOOD Glucose-97 UreaN-32* Creat-6.1*# Na-135 K-5.0 Cl-93* HCO3-31 AnGap-16 [MASKED] 09:35AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 IMAGING: --------- CXR [MASKED] 1. Mild-to-moderate pulmonary vascular congestion, diffuse bilateral interstitial edema, and trace right pleural effusion suggest volume overload. 2. Bilateral linear atelectasis. PARACENTESIS [MASKED] Technically successful ultrasound-guided therapeutic paracentesis, yielding 4 L of clear, straw-colored ascitic fluid. Brief Hospital Course: [MASKED] w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presenting with ulceration over her AV fistula. # AVF ulceration: New ulceration on site of AVF, perhaps from patient self-applying tape over the fistula. Underwent fistula revision [MASKED]. # ESRD s/p ECD kidney transplant in [MASKED] c/b chronic allograft nephropathy: Chronic focal segmental glomerulosclerosis. Was on dialysis from [MASKED]. Had a transplant in [MASKED], but failed in [MASKED]. Resumed dialysis in [MASKED], MWF with LUE AVF. Continued home medications. Had session of HD [MASKED] prior to discharge without complications. Resume MWF schedule. # Anemia: Likely from low epo and anemia of chronic disease. Continued Epo 60,000U qHD # Cryptogenic cirrhosis: Perhaps cardiac cirrhosis in setting of right-sided heart failure. Complicated by portal hypertension with ascites and splenomegaly. Up to date on variceal and HCC screening based on most recent Hepatology note. Last EGD [MASKED] found large hiatal hernia. Has q2 week paracentesis, due again on [MASKED]. Received [MASKED] guided paracentesis on [MASKED] with 4L fluid removed. #Concern for gyn malignancy: Concern for ovarian or other malignancy as a cause of ascites, elevated CA-125 (276 on [MASKED]. Patient was offered MRI as an inpatient (both sedated or regular with premedication) but declined despite counseling of the risks. She reports that she did not want to be out of it with breathing support but also could not be enclosed. She raised the idea of an open MRI and discussed that image quality is not as good but patient was adamant. Primary care doctor was contacted regarding open MRI. # Aflutter # Afib: Was previously on Coumadin and carvedilol. The Coumadin was stopped in [MASKED] secondary to frequent fistula bleeding events. It was restarted in [MASKED]. Risk of hemorrhagic stroke is higher with warfarin use in [MASKED] HD patients. No current anticoagulation. # COPD: On 3L home O2 since [MASKED]. Continued home management. # Chronic diastolic heart failure # Pulmonary hypertension: Seen by cardiology in [MASKED]. Not on any cardiac meds due to hypotension. Unable to aggressively remove fluid with UF due to hypotension as well. # GERD: Continued home pantoprazole TRANSITIONAL ISSUES: - Patient needs open MRI to evaluate for possible malignancy #Code Status: Presumed full code #Emergency Contact/HCP: [MASKED] ([MASKED]), alternate contact is [MASKED], sister ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN wheeze 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Nephrocaps 1 CAP PO DAILY 5. Calcium Acetate 667 mg PO TID W/MEALS 6. Pantoprazole 40 mg PO Q24H 7. HydrOXYzine 25 mg PO Q4H:PRN pruritis Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN wheeze 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. HydrOXYzine 25 mg PO Q4H:PRN pruritis 6. Nephrocaps 1 CAP PO DAILY 7. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: AV Fistula Ulceration ESRD on HD Cryptogenic cirrhosis COPD on home O2 atrial fibrillation/flutter portal hypertension with ascites and splenomegaly chronic diastolic heart failure pulmonary hypertension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital because you had a problem with your fistula. It was fixed in a procedure called a fistula revision. You had a dialysis session on [MASKED] that went well so you can continue your regular dialysis schedule. You had a lot of fluid in your abdomen that was removed by our radiology team. You need an MRI of your abdomen to help figure out why you have all of this fluid building up. You were offered this test while you were here but you felt claustrophobic and you did not want to be sedated either. Instead you were hoping to have an open MRI. Please talk to your primary care doctor about scheduling this important test. Please see your follow-up appointments below. It was a pleasure caring for you and we wish you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I5032", "F17210", "J449", "I4891", "K219", "F329", "Y929" ]
[ "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "N186: End stage renal disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "T8612: Kidney transplant failure", "R188: Other ascites", "K766: Portal hypertension", "I272: Other secondary pulmonary hypertension", "I5032: Chronic diastolic (congestive) heart failure", "I4892: Unspecified atrial flutter", "L98499: Non-pressure chronic ulcer of skin of other sites with unspecified severity", "D631: Anemia in chronic kidney disease", "D638: Anemia in other chronic diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z23: Encounter for immunization", "Z992: Dependence on renal dialysis", "J449: Chronic obstructive pulmonary disease, unspecified", "Z9981: Dependence on supplemental oxygen", "R234: Changes in skin texture", "R161: Splenomegaly, not elsewhere classified", "I4891: Unspecified atrial fibrillation", "K219: Gastro-esophageal reflux disease without esophagitis", "K7469: Other cirrhosis of liver", "K449: Diaphragmatic hernia without obstruction or gangrene", "F40240: Claustrophobia", "F329: Major depressive disorder, single episode, unspecified", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,055,694
27,416,032
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors / lisinopril Attending: ___. Chief Complaint: SOB Major Surgical or Invasive Procedure: R femoral CVL Paracentesis History of Present Illness: ___ w/ PMHx of ESRD s/p failed renal transplant now on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, who presents with shortness of breath and cough. Patient is a poor historian so history is obtained via ED dash and limited conversation with patient. Reports has been feeling feverish at home. Reports has been having a productive cough over the last week. Patient lives alone. She woke up this morning feeling worse and called her daughter who was worried about her breathing and eventually convinced her to come to the emergency room. Patient reports her blood pressure is often low in the ___. Denies any chest pain at this time. Recent history notable for LVP on ___ with 3.8L fluid removed and HD on ___ with additional 3L removed. In ED initial VS: 99.8, 102, 60/38, 34, 92% Nasal Cannula Exam: None documented in ED Labs significant for: CBC 15.8/9.1/30.4/319, Chem 7: Cr 3.0, K 3.6, MG 1.5, Lactate 1.6 Patient was given: ___ 20:33 IV Vancomycin (1000 mg ordered) ___ Started Stop ___ 20:33 PO Acetaminophen 1000 mg ___ ___ 20:33 IVF NS ( 250 mL ordered) ___ Started ___ 21:22 IVF NS ( 250 mL ordered) ___ Started Stop ___ 21:37 IV Piperacillin-Tazobactam (4.5 g ordered) ___ Started ___ 22:21 IV Albumin 25% (12.5g / 50mL) 25 g ___ Imaging notable for: - CXR: Moderate pulmonary edema, worse in the interval, with increased size of right pleural effusion, now moderate in extent. Probable small left pleural effusion as well. Bibasilar airspace opacities, more so on the right, could reflect compressive atelectasis, though infection is difficult to exclude. Right femoral line was placed in the ED, with initiation of Levophed. VS prior to transfer: 98.5, 95, 100/37, 19, 95% Nasal Cannula On arrival to the MICU, patient reports feeling much improved. She provides the history as above but does not elaborate further. Denies any abdominal pain or chest pain. breathing is at her baseline. no recent sick contacts. Per review of OMR medications, patient would have completed a prolonged 1 month prednisone taper on ___ if taking as prescribed. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - H/O syphilis - H/O Breast Cysts - PELVIC MASS - ASCITES - Cryptogenic CIRRHOSIS PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: She denies a family history of liver disease. Family history of father with atherosclerotic CVD. Mother with diabetes on dialysis. No history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: Afebrile, 96/52, HR ___, 92 5L NC GENERAL: Alert, oriented, appears in pain, moving around the bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Diffuse harsh rhonchi and end expiratory wheezes, decreased breath sounds right base midway up lungs. CV: Tachycardic, irregular. ABD: +BS, distended, soft, non-tender, no rebound tenderness or guardin EXT: Left leg cooler compared with right leg, no clubbing, cyanosis or edema. LUE fistula with palpable thrill, audible bruit SKIN: xerotic skin, no ulcerations or erythema noted NEURO: AOx3, moving all extremities DISCHARGE PHYSICAL EXAM On exam, patient was still. Pulses in absent in bilateral carotid arteries. Absent withdrawal to painful stimuli. Pupils fixed/dilated, non-responsive to light bilaterally. No heart sounds or breath sounds appreciated on auscultation. No chest rise appreciated on palpation. Time of death was 1518. Patient's family was present at the time of death. Pertinent Results: LABS ON ADMISSION ================== ___ 08:19PM BLOOD WBC-15.8*# RBC-3.39* Hgb-9.1* Hct-30.4* MCV-90 MCH-26.8 MCHC-29.9* RDW-19.5* RDWSD-63.0* Plt ___ ___ 08:19PM BLOOD Neuts-79.3* Lymphs-12.2* Monos-7.6 Eos-0.1* Baso-0.3 NRBC-0.1* Im ___ AbsNeut-12.51*# AbsLymp-1.92 AbsMono-1.20* AbsEos-0.01* AbsBaso-0.05 ___ 09:20AM BLOOD ___ ___ 08:19PM BLOOD Glucose-95 UreaN-11 Creat-3.0*# Na-138 K-3.6 Cl-92* HCO3-34* AnGap-12 ___ 08:19PM BLOOD ALT-9 AST-25 AlkPhos-128* TotBili-1.0 ___ 08:19PM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.3* Mg-1.5* ___ 08:26PM BLOOD ___ pO2-22* pCO2-57* pH-7.44 calTCO2-40* Base XS-10 NOTABLE LABS ============ ___ 09:55PM ASCITES TNC-250* RBC-9165* Polys-16* Lymphs-36* Monos-46* Basos-2* ___ 09:55PM ASCITES TotPro-4.9 Albumin-1.9 ___ 2:30 pm BLOOD CULTURE Source: Line-Fem line. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 9:55 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. LABS ON DISCHARGE ================= ___ 05:29AM BLOOD WBC-11.9* RBC-3.41* Hgb-9.2* Hct-32.2* MCV-94 MCH-27.0 MCHC-28.6* RDW-22.5* RDWSD-72.6* Plt ___ ___ 07:25AM BLOOD Neuts-62.0 ___ Monos-12.3 Eos-1.8 Baso-1.2* NRBC-0.2* Im ___ AbsNeut-5.48 AbsLymp-1.95 AbsMono-1.09* AbsEos-0.16 AbsBaso-0.11* ___ 05:29AM BLOOD Glucose-99 UreaN-21* Creat-5.0*# Na-140 K-4.2 Cl-102 HCO3-26 AnGap-12 ___ 05:29AM BLOOD ALT-10 AST-22 LD(LDH)-173 AlkPhos-194* TotBili-0.7 ___ 05:29AM BLOOD Calcium-10.5* Phos-5.4* Mg-2.4 ___ 05:58AM BLOOD ___ pO2-50* pCO2-69* pH-7.23* calTCO2-30 Base XS-0 ___ 05:58AM BLOOD Lactate-1.___ w/ PMHx of ESRD s/p failed renal transplant now on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, who presents with fever, shortness of breath and cough, admitted to ICU with sepsis and who eventually died due to complications from ongoing hypotension, ESRD and seizure. ICU Course =========== # Mixed shock. Presented with fever & leukocytosis, in setting of known systolic heart failure and low CVO2. No lactate elevation to suggest hypoperfusion. Most likely source is pulmonary given cough, CXR findings. Infected ascites less likely since she has not had acute abdominal pain and exam was benign. Had paracentesis on ___ that was negative for SBP. Treated with vancomycin/cefepime/Azithromycin (possible hives to penicillins). TTE was performed on ___ which showed dilated and hypokinetic right ventricle with pressure/volume overload, signs of pulmonary hypertension, severe tricuspid regurgitation w/ nl LV function. Patient has known systolic dysfunction, with baseline SBPs ___ in the community. Pt began to have diarrhea and we sent analysis for cdiff and she was found to be positive. The pt was started on oral vanc to treat. Patient required pressor support for most of her admission and uptitration of midodrine. After lack of improvement after treatment of possible pulmonary infection as above and after decline in mental state as below family eventually decided to focus on comfort care and pressors were discontinued. #Seizure Activity Decline in responsiveness and alertness from ___ to ___. EEG started in ___ and found to be in status epilepticus, and given IV Ativan which terminated her seizure. She continued to be very unresponsive after EEG resolution of the seizure. She was started on lacosamide. Flagyl and Cefepime were discontinued given that these can lower the seizure threshold. #Goals of Care Given persistent critically ill state and inability to wean off pressors, family expressed interest in moving patient towards CMO. The family did express interest in CT head and EEG to see if there was easily reversible cause of her encephalopathy. She was found to be in status epilepticus and this was treated, as above. However, given that mental status did not improve even after breaking from status epilepticus, family decided to convert patient to CMO. #Respiratory failure- infection iso COPD. Less likely COPD exacerbation so steroids were not started. Pt had 1L taken off on paracentesis and renal ultrafiltrated to remove additional volume given pleural effusions. #Dialysis. on HD (MWF), continued per normal schedule. Attempted to remove larger volumes through ultrafiltration in an attempt to off-load right heart, given severe dysfunction seen on echo. # Cryptogenic cirrhosis c/b ascites, splenomegaly. Etiology thought to be possibly cardiac from right sided CHF. Currently receiving frequent LVP, last on ___ with 3.8L removed. Pt also had paracentesis in unit on ___ taking off 1L w/o signs of SBP. Last EGD in ___ without varices. CHRONIC ISSUES # Afib/Aflutter # Afib Not on anticoagulation in the setting of past fistula and GI bleeding. HR 100s, irregular not currently on rate control, presumably limited by outpatient hypotension. Rates were not an issue during her hospital stay. # Chronic diastolic heart failure # Pulmonary hypertension: Last TTE in ___, with moderate LV diastolic dysfunction, severe pHTN. Not on medications as limited by hypotension. Pt had a TTE in the hospital which showed pulmonary hypertension, nl EF, w/ severe tricuspid regurgitation and global hypokinesis. # Concern for GYN Malignancy. MRI with e/o matted appearing ovaries, loss of normal architecture, elevated CA-125, cysts with ascites. Evaluated by Dr. ___ in OBGYN, unlikely to be a surgical candidate in the setting of multiple medical comorbidities. Plan was for ongoing discussion in the outpatient setting. # GERD: Continued pantoprazole Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Nephrocaps 1 CAP PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 5. HydrOXYzine 25 mg PO Q4H:PRN itching 6. Midodrine 10 mg PO BEFORE HD 7. Cinacalcet 60 mg PO DAILY Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Mixed Shock Seizure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: ___
[ "A419", "N186", "J9621", "R6521", "I132", "G9340", "J189", "T8612", "I5032", "R188", "N041", "Z515", "Z9981", "K7469", "G40901", "J449", "D649", "I482", "K219", "I071", "R001", "E162", "Z992", "Y830", "Y929", "F17210" ]
Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors / lisinopril Chief Complaint: SOB Major Surgical or Invasive Procedure: R femoral CVL Paracentesis History of Present Illness: [MASKED] w/ PMHx of ESRD s/p failed renal transplant now on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, who presents with shortness of breath and cough. Patient is a poor historian so history is obtained via ED dash and limited conversation with patient. Reports has been feeling feverish at home. Reports has been having a productive cough over the last week. Patient lives alone. She woke up this morning feeling worse and called her daughter who was worried about her breathing and eventually convinced her to come to the emergency room. Patient reports her blood pressure is often low in the [MASKED]. Denies any chest pain at this time. Recent history notable for LVP on [MASKED] with 3.8L fluid removed and HD on [MASKED] with additional 3L removed. In ED initial VS: 99.8, 102, 60/38, 34, 92% Nasal Cannula Exam: None documented in ED Labs significant for: CBC 15.8/9.1/30.4/319, Chem 7: Cr 3.0, K 3.6, MG 1.5, Lactate 1.6 Patient was given: [MASKED] 20:33 IV Vancomycin (1000 mg ordered) [MASKED] Started Stop [MASKED] 20:33 PO Acetaminophen 1000 mg [MASKED] [MASKED] 20:33 IVF NS ( 250 mL ordered) [MASKED] Started [MASKED] 21:22 IVF NS ( 250 mL ordered) [MASKED] Started Stop [MASKED] 21:37 IV Piperacillin-Tazobactam (4.5 g ordered) [MASKED] Started [MASKED] 22:21 IV Albumin 25% (12.5g / 50mL) 25 g [MASKED] Imaging notable for: - CXR: Moderate pulmonary edema, worse in the interval, with increased size of right pleural effusion, now moderate in extent. Probable small left pleural effusion as well. Bibasilar airspace opacities, more so on the right, could reflect compressive atelectasis, though infection is difficult to exclude. Right femoral line was placed in the ED, with initiation of Levophed. VS prior to transfer: 98.5, 95, 100/37, 19, 95% Nasal Cannula On arrival to the MICU, patient reports feeling much improved. She provides the history as above but does not elaborate further. Denies any abdominal pain or chest pain. breathing is at her baseline. no recent sick contacts. Per review of OMR medications, patient would have completed a prolonged 1 month prednisone taper on [MASKED] if taking as prescribed. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD [MASKED]. s/p DCDKD in [MASKED] c/b chronic allograft nephropathy in [MASKED] with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on [MASKED] home oxygen; FEV1 of 57% predicted [MASKED] - Diastolic CHF - Last TTE in [MASKED] with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - H/O syphilis - H/O Breast Cysts - PELVIC MASS - ASCITES - Cryptogenic CIRRHOSIS PAST SURGICAL HISTORY: - Open cholecystectomy [MASKED] - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: [MASKED] Family History: She denies a family history of liver disease. Family history of father with atherosclerotic CVD. Mother with diabetes on dialysis. No history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: Afebrile, 96/52, HR [MASKED], 92 5L NC GENERAL: Alert, oriented, appears in pain, moving around the bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Diffuse harsh rhonchi and end expiratory wheezes, decreased breath sounds right base midway up lungs. CV: Tachycardic, irregular. ABD: +BS, distended, soft, non-tender, no rebound tenderness or guardin EXT: Left leg cooler compared with right leg, no clubbing, cyanosis or edema. LUE fistula with palpable thrill, audible bruit SKIN: xerotic skin, no ulcerations or erythema noted NEURO: AOx3, moving all extremities DISCHARGE PHYSICAL EXAM On exam, patient was still. Pulses in absent in bilateral carotid arteries. Absent withdrawal to painful stimuli. Pupils fixed/dilated, non-responsive to light bilaterally. No heart sounds or breath sounds appreciated on auscultation. No chest rise appreciated on palpation. Time of death was 1518. Patient's family was present at the time of death. Pertinent Results: LABS ON ADMISSION ================== [MASKED] 08:19PM BLOOD WBC-15.8*# RBC-3.39* Hgb-9.1* Hct-30.4* MCV-90 MCH-26.8 MCHC-29.9* RDW-19.5* RDWSD-63.0* Plt [MASKED] [MASKED] 08:19PM BLOOD Neuts-79.3* Lymphs-12.2* Monos-7.6 Eos-0.1* Baso-0.3 NRBC-0.1* Im [MASKED] AbsNeut-12.51*# AbsLymp-1.92 AbsMono-1.20* AbsEos-0.01* AbsBaso-0.05 [MASKED] 09:20AM BLOOD [MASKED] [MASKED] 08:19PM BLOOD Glucose-95 UreaN-11 Creat-3.0*# Na-138 K-3.6 Cl-92* HCO3-34* AnGap-12 [MASKED] 08:19PM BLOOD ALT-9 AST-25 AlkPhos-128* TotBili-1.0 [MASKED] 08:19PM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.3* Mg-1.5* [MASKED] 08:26PM BLOOD [MASKED] pO2-22* pCO2-57* pH-7.44 calTCO2-40* Base XS-10 NOTABLE LABS ============ [MASKED] 09:55PM ASCITES TNC-250* RBC-9165* Polys-16* Lymphs-36* Monos-46* Basos-2* [MASKED] 09:55PM ASCITES TotPro-4.9 Albumin-1.9 [MASKED] 2:30 pm BLOOD CULTURE Source: Line-Fem line. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 9:55 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. LABS ON DISCHARGE ================= [MASKED] 05:29AM BLOOD WBC-11.9* RBC-3.41* Hgb-9.2* Hct-32.2* MCV-94 MCH-27.0 MCHC-28.6* RDW-22.5* RDWSD-72.6* Plt [MASKED] [MASKED] 07:25AM BLOOD Neuts-62.0 [MASKED] Monos-12.3 Eos-1.8 Baso-1.2* NRBC-0.2* Im [MASKED] AbsNeut-5.48 AbsLymp-1.95 AbsMono-1.09* AbsEos-0.16 AbsBaso-0.11* [MASKED] 05:29AM BLOOD Glucose-99 UreaN-21* Creat-5.0*# Na-140 K-4.2 Cl-102 HCO3-26 AnGap-12 [MASKED] 05:29AM BLOOD ALT-10 AST-22 LD(LDH)-173 AlkPhos-194* TotBili-0.7 [MASKED] 05:29AM BLOOD Calcium-10.5* Phos-5.4* Mg-2.4 [MASKED] 05:58AM BLOOD [MASKED] pO2-50* pCO2-69* pH-7.23* calTCO2-30 Base XS-0 [MASKED] 05:58AM BLOOD Lactate-1.[MASKED] w/ PMHx of ESRD s/p failed renal transplant now on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, who presents with fever, shortness of breath and cough, admitted to ICU with sepsis and who eventually died due to complications from ongoing hypotension, ESRD and seizure. ICU Course =========== # Mixed shock. Presented with fever & leukocytosis, in setting of known systolic heart failure and low CVO2. No lactate elevation to suggest hypoperfusion. Most likely source is pulmonary given cough, CXR findings. Infected ascites less likely since she has not had acute abdominal pain and exam was benign. Had paracentesis on [MASKED] that was negative for SBP. Treated with vancomycin/cefepime/Azithromycin (possible hives to penicillins). TTE was performed on [MASKED] which showed dilated and hypokinetic right ventricle with pressure/volume overload, signs of pulmonary hypertension, severe tricuspid regurgitation w/ nl LV function. Patient has known systolic dysfunction, with baseline SBPs [MASKED] in the community. Pt began to have diarrhea and we sent analysis for cdiff and she was found to be positive. The pt was started on oral vanc to treat. Patient required pressor support for most of her admission and uptitration of midodrine. After lack of improvement after treatment of possible pulmonary infection as above and after decline in mental state as below family eventually decided to focus on comfort care and pressors were discontinued. #Seizure Activity Decline in responsiveness and alertness from [MASKED] to [MASKED]. EEG started in [MASKED] and found to be in status epilepticus, and given IV Ativan which terminated her seizure. She continued to be very unresponsive after EEG resolution of the seizure. She was started on lacosamide. Flagyl and Cefepime were discontinued given that these can lower the seizure threshold. #Goals of Care Given persistent critically ill state and inability to wean off pressors, family expressed interest in moving patient towards CMO. The family did express interest in CT head and EEG to see if there was easily reversible cause of her encephalopathy. She was found to be in status epilepticus and this was treated, as above. However, given that mental status did not improve even after breaking from status epilepticus, family decided to convert patient to CMO. #Respiratory failure- infection iso COPD. Less likely COPD exacerbation so steroids were not started. Pt had 1L taken off on paracentesis and renal ultrafiltrated to remove additional volume given pleural effusions. #Dialysis. on HD (MWF), continued per normal schedule. Attempted to remove larger volumes through ultrafiltration in an attempt to off-load right heart, given severe dysfunction seen on echo. # Cryptogenic cirrhosis c/b ascites, splenomegaly. Etiology thought to be possibly cardiac from right sided CHF. Currently receiving frequent LVP, last on [MASKED] with 3.8L removed. Pt also had paracentesis in unit on [MASKED] taking off 1L w/o signs of SBP. Last EGD in [MASKED] without varices. CHRONIC ISSUES # Afib/Aflutter # Afib Not on anticoagulation in the setting of past fistula and GI bleeding. HR 100s, irregular not currently on rate control, presumably limited by outpatient hypotension. Rates were not an issue during her hospital stay. # Chronic diastolic heart failure # Pulmonary hypertension: Last TTE in [MASKED], with moderate LV diastolic dysfunction, severe pHTN. Not on medications as limited by hypotension. Pt had a TTE in the hospital which showed pulmonary hypertension, nl EF, w/ severe tricuspid regurgitation and global hypokinesis. # Concern for GYN Malignancy. MRI with e/o matted appearing ovaries, loss of normal architecture, elevated CA-125, cysts with ascites. Evaluated by Dr. [MASKED] in OBGYN, unlikely to be a surgical candidate in the setting of multiple medical comorbidities. Plan was for ongoing discussion in the outpatient setting. # GERD: Continued pantoprazole Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Nephrocaps 1 CAP PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 5. HydrOXYzine 25 mg PO Q4H:PRN itching 6. Midodrine 10 mg PO BEFORE HD 7. Cinacalcet 60 mg PO DAILY Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Mixed Shock Seizure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: [MASKED]
[]
[ "I5032", "Z515", "J449", "D649", "K219", "Y929", "F17210" ]
[ "A419: Sepsis, unspecified organism", "N186: End stage renal disease", "J9621: Acute and chronic respiratory failure with hypoxia", "R6521: Severe sepsis with septic shock", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "G9340: Encephalopathy, unspecified", "J189: Pneumonia, unspecified organism", "T8612: Kidney transplant failure", "I5032: Chronic diastolic (congestive) heart failure", "R188: Other ascites", "N041: Nephrotic syndrome with focal and segmental glomerular lesions", "Z515: Encounter for palliative care", "Z9981: Dependence on supplemental oxygen", "K7469: Other cirrhosis of liver", "G40901: Epilepsy, unspecified, not intractable, with status epilepticus", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "I482: Chronic atrial fibrillation", "K219: Gastro-esophageal reflux disease without esophagitis", "I071: Rheumatic tricuspid insufficiency", "R001: Bradycardia, unspecified", "E162: Hypoglycemia, unspecified", "Z992: Dependence on renal dialysis", "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", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,055,729
20,488,889
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: Outpatient LFT abnormalities and planned liver biopsy. Major Surgical or Invasive Procedure: Percutaneous Liver Biopsy ___ History of Present Illness: ___ with h/o RCC s/p L nephrectomy (___), T2DM, HCV cirrhosis (MELD 10) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA (___) and SMV/PV thrombosis (on Coumadin) s/p DDLT in ___ who presented for evaluation of LFT abnormalities and planned liver biopsy. Outpatient laboratory work up recently notable for WBC of 5.3, Hgb 11.2, Plt count 234 (___), INR 1.1, chemistry WNL, ALT 29, AST 45 (30 previously) Tbili 0.4. Patient admitted for repeat MRCP and liver biopsy. Of note patient was admitted ___ in the setting of LFT abnormalities. MRCP showed stricture at the biliary anastomosis, with dilation of the extrahepatic biliary tree both above and below the anastomosis. He underwent ERCP for stenting. Per the report the cannulation was very difficult and required precut sphincterotomy. A 0.2cm benign appearing stricture at the mid-CBD was noted and a stent was placed. On arrival to the floor, Mr. ___ had no acute complaints. He notes some persistent swelling of his lower extremities. No chest pain, dyspnea, abdominal pain has been ongoing since initial stent placement. Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion (___) with no new e/o disease on ___ MRI - h/o SMV/PV thrombosis (dx'd ___ on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC (___) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW (___) - h/o L inguinal hernia repair (age ___ Social History: ___ Family History: no h/o cirrhosis/malignancy Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: ___ 1848 Temp: 98.4 PO BP: 164/90 HR: 86 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Bilateral non-pitting edema. No cyanosis, clubbing PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ========================= VS: T 98.4, BP 144/86, HR 76, RR 18, O2 sat 98 Ra GENERAL: NAD, lying in bed. Responding to questions HEENT: Anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, mild tenderness in RUQ near biopsy site, no rebound/guarding EXTREMITIES: Bilateral non-pitting edema. No cyanosis, clubbing 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 Pertinent Results: ADMISSION LABS: ================== ___ 10:10PM BLOOD WBC-3.4* RBC-4.01* Hgb-10.3* Hct-33.5* MCV-84 MCH-25.7* MCHC-30.7* RDW-15.9* RDWSD-48.4* Plt ___ ___ 10:10PM BLOOD ___ PTT-28.8 ___ ___ 10:10PM BLOOD Glucose-176* UreaN-25* Creat-1.4* Na-139 K-4.9 Cl-104 HCO3-23 AnGap-12 ___ 10:15AM BLOOD ALT-29 AST-45* AlkPhos-159* TotBili-0.4 ___ 10:15AM BLOOD GGT-207* ___ 10:15AM BLOOD Albumin-4.1 ___ 10:15AM BLOOD CMV VL-NOT DETECT MICROBIOLOGY: =================== Urine Culture ___ - Negative IMAGING: ============== CHEST (PORTABLE AP)Study Date of ___ There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. Surgical clips the biliary stent are seen in the upper abdomen. ------------ DUPLEX DOPP ABD/PELStudy Date of ___ 1. Patent hepatic vasculature. 2. Possible left intrahepatic biliary ductal dilation vs fluid in the fissure along the falciform ligament. ------------ MRCP (MR ABD ___ Date of ___ 1. Interval resolution of the biliary dilation status post stenting across the biliary anastomotic stricture. 2. Redemonstration of peripheral subcapsular areas of progressive parenchymal enhancement with associated T2 hyperintense signal in the transplant liver, likely representing areas of fibrotic changes or sequela of prior ischemic injury. 3. Mild focal attenuation of the intrahepatic segment of the supra-celiac arterial conduit, which is patent distally, unchanged from prior. 4. Interval resolution of previously seen fluid collections in the low abdomen/pelvis. Decreased size small Morison's pouch hematomas. 5. Small right pleural effusion. TACROLIMUS LEVELS: =================== ___ 05:08AM BLOOD tacroFK-6.1 ___ 07:32AM BLOOD tacroFK-6.3 ___ 07:18AM BLOOD tacroFK-8.7 ___ 05:25AM BLOOD tacroFK-PND DISCHARGE LABS: ================= ___ 05:25AM BLOOD WBC-3.6* RBC-4.44* Hgb-10.9* Hct-36.1* MCV-81* MCH-24.5* MCHC-30.2* RDW-15.3 RDWSD-45.4 Plt ___ ___ 05:25AM BLOOD ___ PTT-27.8 ___ ___ 05:25AM BLOOD Glucose-128* UreaN-20 Creat-1.3* Na-135 K-5.1 Cl-98 HCO3-22 AnGap-15 ___ 05:25AM BLOOD ALT-29 AST-33 LD(LDH)-213 AlkPhos-171* TotBili-0.3 ___ 05:25AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.7 Brief Hospital Course: Patient Summary for Discharge: ___ with h/o RCC s/p L nephrectomy (___), T2DM, HCV cirrhosis (MELD 10) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA (___) and SMV/PV thrombosis s/p DDLT in ___ who presented for evaluation of LFT abnormalities and planned liver biopsy. ACTIVE ISSUES: ================= #LFT abnormalities #History of stricture at the biliary anastomosis: Patient with slight increase in AST from labs with negative infectious work up to date (CMV and EBV negative). MRCR ___ without dilatation which raised concern for rejection as underlying etiology of transaminitis. Percutaneous liver biopsy was completed on ___ and preliminary results showed mild inflammation, indeterminate for rejection. As a result the focus management became therapeutic Tacrolimus dosing. His dose was increased to 5mg twice daily and level as of 10.7 was 8.7 which was within the therapeutic window of ___. Prior to discharge his ALT as 29 and AST 33, Tbili 0.3 and he was felt appropriate for discharge. #HCV cirrhosis #s/p Liver Tx on ___ for HCV cirrhosis(treated) c/b HCC required CVVH post Tx which was stopped on ___, LFTs discussed above. Since last admission has completed Fluconazole and Prednisone course. He is continued on home regimen including: Mycophenolate Mofetil 1000mg PO BID, Tacrolimus which was increased to 5mg BID as discussed above. For ppx he continued ValGANCIclovir 900 mg PO Q24H, Dapsone 100 mg PO and omeprazole for GI ppx. #CKD: Baseline Sr Cr 1.0-1.6. However, on presentation the Cr was 1.4 which remained stable from recent baseline within last month. CHRONIC ISSUES: =============== #Gout: He was continued on allopurinol ___ daily #Constipation: He was continued on home docusate, senna, lactulose. Additionally patient noted ongoing constipation and Miralax and Bisacodyl suppositories were added as PRN medications. Magnesium Oxide previously used for constipation was discontinued. #Hypertension: He was continued on home metoprolol tartrate 25mg and aspirin prophylaxis was restarted prior to discharge. #Chronic pain. He was continued on home meds: Continued home Gabapentin, Oxycodone, Morphine ER. #Diabetes: Continue home regimen NPH 22 units QAM and QPM with 3 units Humalog scheduled with lunch and dinner. TRANSITIONAL ISSUES: ====================== Pending labs at discharge: Labs ___ 05:25 TACROLIMUS Microbiology ___ 12:15 BLOOD CULTURE Blood Culture, Routine ___ 22:19 BLOOD CULTURE Blood Culture, Routine Diagnostic Reports ___ Tissue: LIVER, MEDICAL BIOPSY OR WEDGE [ ] Next Tacrolimus level should be drawn on ___ and faxed to the Liver ___ at ___. Levels should continued to be drawn 2x weekly. [ ] Tacrolimus dose increased to 5mg BID with a goal level to ___ [ ] Tacrolimus level from ___ pending at discharge. Any further dose adjustments will be communicated to ___ facility following discharge. [ ] Biopsy results pending at time of discharge and will be follow up by outpatient Hepatology team. [ ] Patient noted ongoing constipation while inpatient and his bowel regimen was expanded. Patient can use Senna, Colace, Bisacodyl, Lactulose and Miralax PRN. Medication Changes: - New Medications: Miralax daily PRN for constipation - Changed Medications: Tacrolimus dosing increased to 5mg BID - Stopped Medications: Magnesium Oxide Code Status: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 100 mg PO BID 5. Metoprolol Tartrate 25 mg PO BID 6. Mycophenolate Mofetil 1000 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 9. Senna 8.6 mg PO QHS 10. Tacrolimus 3 mg PO Q12H 11. ValGANCIclovir 900 mg PO Q24H 12. Allopurinol ___ mg PO BID 13. Amitriptyline 25 mg PO QHS 14. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 15. Lactulose 30 mL PO BID:PRN constipation 16. Magnesium Oxide 400 mg PO BID 17. morphine 10 mg oral DAILY:PRN pain management 18. vitamin A and D 1 application topical QHS 19. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 20. Atorvastatin 20 mg PO QPM 21. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 22. Simethicone 80 mg PO TID:PRN gas pain 23. Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 3. Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime 4. Tacrolimus 5 mg PO Q12H 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 6. Allopurinol ___ mg PO BID 7. Amitriptyline 25 mg PO QHS 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Dapsone 100 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Gabapentin 100 mg PO BID 13. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 14. Lactulose 30 mL PO BID:PRN constipation 15. Metoprolol Tartrate 25 mg PO BID 16. morphine 10 mg oral DAILY:PRN pain management 17. Mycophenolate Mofetil 1000 mg PO BID 18. Omeprazole 20 mg PO DAILY 19. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 20. Senna 8.6 mg PO QHS 21. Simethicone 80 mg PO TID:PRN gas pain 22. ValGANCIclovir 900 mg PO Q24H 23. vitamin A and D 1 application topical QHS 24. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 25. HELD- Magnesium Oxide 400 mg PO BID This medication was held. Do not restart Magnesium Oxide until instructed to do so by the liver team 26.Outpatient Lab Work ICD 9: V42.7 To be drawn: ___ Draw: Tacrolimus Level Fax to: Dr. ___ Fax ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== History of HCV Cirrhosis s/p Liver Tx on ___ Transaminitis Chronic Kidney Disease Secondary Diagnosis: ===================== Chronic Pain Insulin Dependent Diabetes 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 of concern regarding your transplanted liver and possible rejection WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We examined your liver with ultrasound which showed no vasculature problems and with MRCP which showed no changes in your liver bile ducts - We completed a biopsy of your liver which did not show definite rejection. To help protect your liver we increased your Tacrolimus dose to 5mg twice daily. - We treated your abdominal pain with your home medication. - 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: ___
[ "R945", "Z944", "Z85528", "Z8505", "I129", "E1122", "N189", "Z87891", "Z905", "K5900", "Z8619", "R1012" ]
Allergies: Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: Outpatient LFT abnormalities and planned liver biopsy. Major Surgical or Invasive Procedure: Percutaneous Liver Biopsy [MASKED] History of Present Illness: [MASKED] with h/o RCC s/p L nephrectomy ([MASKED]), T2DM, HCV cirrhosis (MELD 10) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ([MASKED]) and SMV/PV thrombosis (on Coumadin) s/p DDLT in [MASKED] who presented for evaluation of LFT abnormalities and planned liver biopsy. Outpatient laboratory work up recently notable for WBC of 5.3, Hgb 11.2, Plt count 234 ([MASKED]), INR 1.1, chemistry WNL, ALT 29, AST 45 (30 previously) Tbili 0.4. Patient admitted for repeat MRCP and liver biopsy. Of note patient was admitted [MASKED] in the setting of LFT abnormalities. MRCP showed stricture at the biliary anastomosis, with dilation of the extrahepatic biliary tree both above and below the anastomosis. He underwent ERCP for stenting. Per the report the cannulation was very difficult and required precut sphincterotomy. A 0.2cm benign appearing stricture at the mid-CBD was noted and a stent was placed. On arrival to the floor, Mr. [MASKED] had no acute complaints. He notes some persistent swelling of his lower extremities. No chest pain, dyspnea, abdominal pain has been ongoing since initial stent placement. Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion ([MASKED]) with no new e/o disease on [MASKED] MRI - h/o SMV/PV thrombosis (dx'd [MASKED] on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC ([MASKED]) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW ([MASKED]) - h/o L inguinal hernia repair (age [MASKED] Social History: [MASKED] Family History: no h/o cirrhosis/malignancy Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: [MASKED] 1848 Temp: 98.4 PO BP: 164/90 HR: 86 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Bilateral non-pitting edema. No cyanosis, clubbing PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ========================= VS: T 98.4, BP 144/86, HR 76, RR 18, O2 sat 98 Ra GENERAL: NAD, lying in bed. Responding to questions HEENT: Anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, mild tenderness in RUQ near biopsy site, no rebound/guarding EXTREMITIES: Bilateral non-pitting edema. No cyanosis, clubbing 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 Pertinent Results: ADMISSION LABS: ================== [MASKED] 10:10PM BLOOD WBC-3.4* RBC-4.01* Hgb-10.3* Hct-33.5* MCV-84 MCH-25.7* MCHC-30.7* RDW-15.9* RDWSD-48.4* Plt [MASKED] [MASKED] 10:10PM BLOOD [MASKED] PTT-28.8 [MASKED] [MASKED] 10:10PM BLOOD Glucose-176* UreaN-25* Creat-1.4* Na-139 K-4.9 Cl-104 HCO3-23 AnGap-12 [MASKED] 10:15AM BLOOD ALT-29 AST-45* AlkPhos-159* TotBili-0.4 [MASKED] 10:15AM BLOOD GGT-207* [MASKED] 10:15AM BLOOD Albumin-4.1 [MASKED] 10:15AM BLOOD CMV VL-NOT DETECT MICROBIOLOGY: =================== Urine Culture [MASKED] - Negative IMAGING: ============== CHEST (PORTABLE AP)Study Date of [MASKED] There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. Surgical clips the biliary stent are seen in the upper abdomen. ------------ DUPLEX DOPP ABD/PELStudy Date of [MASKED] 1. Patent hepatic vasculature. 2. Possible left intrahepatic biliary ductal dilation vs fluid in the fissure along the falciform ligament. ------------ MRCP (MR ABD [MASKED] Date of [MASKED] 1. Interval resolution of the biliary dilation status post stenting across the biliary anastomotic stricture. 2. Redemonstration of peripheral subcapsular areas of progressive parenchymal enhancement with associated T2 hyperintense signal in the transplant liver, likely representing areas of fibrotic changes or sequela of prior ischemic injury. 3. Mild focal attenuation of the intrahepatic segment of the supra-celiac arterial conduit, which is patent distally, unchanged from prior. 4. Interval resolution of previously seen fluid collections in the low abdomen/pelvis. Decreased size small Morison's pouch hematomas. 5. Small right pleural effusion. TACROLIMUS LEVELS: =================== [MASKED] 05:08AM BLOOD tacroFK-6.1 [MASKED] 07:32AM BLOOD tacroFK-6.3 [MASKED] 07:18AM BLOOD tacroFK-8.7 [MASKED] 05:25AM BLOOD tacroFK-PND DISCHARGE LABS: ================= [MASKED] 05:25AM BLOOD WBC-3.6* RBC-4.44* Hgb-10.9* Hct-36.1* MCV-81* MCH-24.5* MCHC-30.2* RDW-15.3 RDWSD-45.4 Plt [MASKED] [MASKED] 05:25AM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 05:25AM BLOOD Glucose-128* UreaN-20 Creat-1.3* Na-135 K-5.1 Cl-98 HCO3-22 AnGap-15 [MASKED] 05:25AM BLOOD ALT-29 AST-33 LD(LDH)-213 AlkPhos-171* TotBili-0.3 [MASKED] 05:25AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.7 Brief Hospital Course: Patient Summary for Discharge: [MASKED] with h/o RCC s/p L nephrectomy ([MASKED]), T2DM, HCV cirrhosis (MELD 10) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ([MASKED]) and SMV/PV thrombosis s/p DDLT in [MASKED] who presented for evaluation of LFT abnormalities and planned liver biopsy. ACTIVE ISSUES: ================= #LFT abnormalities #History of stricture at the biliary anastomosis: Patient with slight increase in AST from labs with negative infectious work up to date (CMV and EBV negative). MRCR [MASKED] without dilatation which raised concern for rejection as underlying etiology of transaminitis. Percutaneous liver biopsy was completed on [MASKED] and preliminary results showed mild inflammation, indeterminate for rejection. As a result the focus management became therapeutic Tacrolimus dosing. His dose was increased to 5mg twice daily and level as of 10.7 was 8.7 which was within the therapeutic window of [MASKED]. Prior to discharge his ALT as 29 and AST 33, Tbili 0.3 and he was felt appropriate for discharge. #HCV cirrhosis #s/p Liver Tx on [MASKED] for HCV cirrhosis(treated) c/b HCC required CVVH post Tx which was stopped on [MASKED], LFTs discussed above. Since last admission has completed Fluconazole and Prednisone course. He is continued on home regimen including: Mycophenolate Mofetil 1000mg PO BID, Tacrolimus which was increased to 5mg BID as discussed above. For ppx he continued ValGANCIclovir 900 mg PO Q24H, Dapsone 100 mg PO and omeprazole for GI ppx. #CKD: Baseline Sr Cr 1.0-1.6. However, on presentation the Cr was 1.4 which remained stable from recent baseline within last month. CHRONIC ISSUES: =============== #Gout: He was continued on allopurinol [MASKED] daily #Constipation: He was continued on home docusate, senna, lactulose. Additionally patient noted ongoing constipation and Miralax and Bisacodyl suppositories were added as PRN medications. Magnesium Oxide previously used for constipation was discontinued. #Hypertension: He was continued on home metoprolol tartrate 25mg and aspirin prophylaxis was restarted prior to discharge. #Chronic pain. He was continued on home meds: Continued home Gabapentin, Oxycodone, Morphine ER. #Diabetes: Continue home regimen NPH 22 units QAM and QPM with 3 units Humalog scheduled with lunch and dinner. TRANSITIONAL ISSUES: ====================== Pending labs at discharge: Labs [MASKED] 05:25 TACROLIMUS Microbiology [MASKED] 12:15 BLOOD CULTURE Blood Culture, Routine [MASKED] 22:19 BLOOD CULTURE Blood Culture, Routine Diagnostic Reports [MASKED] Tissue: LIVER, MEDICAL BIOPSY OR WEDGE [ ] Next Tacrolimus level should be drawn on [MASKED] and faxed to the Liver [MASKED] at [MASKED]. Levels should continued to be drawn 2x weekly. [ ] Tacrolimus dose increased to 5mg BID with a goal level to [MASKED] [ ] Tacrolimus level from [MASKED] pending at discharge. Any further dose adjustments will be communicated to [MASKED] facility following discharge. [ ] Biopsy results pending at time of discharge and will be follow up by outpatient Hepatology team. [ ] Patient noted ongoing constipation while inpatient and his bowel regimen was expanded. Patient can use Senna, Colace, Bisacodyl, Lactulose and Miralax PRN. Medication Changes: - New Medications: Miralax daily PRN for constipation - Changed Medications: Tacrolimus dosing increased to 5mg BID - Stopped Medications: Magnesium Oxide Code Status: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 100 mg PO BID 5. Metoprolol Tartrate 25 mg PO BID 6. Mycophenolate Mofetil 1000 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 9. Senna 8.6 mg PO QHS 10. Tacrolimus 3 mg PO Q12H 11. ValGANCIclovir 900 mg PO Q24H 12. Allopurinol [MASKED] mg PO BID 13. Amitriptyline 25 mg PO QHS 14. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 15. Lactulose 30 mL PO BID:PRN constipation 16. Magnesium Oxide 400 mg PO BID 17. morphine 10 mg oral DAILY:PRN pain management 18. vitamin A and D 1 application topical QHS 19. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) 20. Atorvastatin 20 mg PO QPM 21. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 22. Simethicone 80 mg PO TID:PRN gas pain 23. Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 3. Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime 4. Tacrolimus 5 mg PO Q12H 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 6. Allopurinol [MASKED] mg PO BID 7. Amitriptyline 25 mg PO QHS 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Dapsone 100 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Gabapentin 100 mg PO BID 13. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 14. Lactulose 30 mL PO BID:PRN constipation 15. Metoprolol Tartrate 25 mg PO BID 16. morphine 10 mg oral DAILY:PRN pain management 17. Mycophenolate Mofetil 1000 mg PO BID 18. Omeprazole 20 mg PO DAILY 19. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 20. Senna 8.6 mg PO QHS 21. Simethicone 80 mg PO TID:PRN gas pain 22. ValGANCIclovir 900 mg PO Q24H 23. vitamin A and D 1 application topical QHS 24. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) 25. HELD- Magnesium Oxide 400 mg PO BID This medication was held. Do not restart Magnesium Oxide until instructed to do so by the liver team 26.Outpatient Lab Work ICD 9: V42.7 To be drawn: [MASKED] Draw: Tacrolimus Level Fax to: Dr. [MASKED] Fax [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== History of HCV Cirrhosis s/p Liver Tx on [MASKED] Transaminitis Chronic Kidney Disease Secondary Diagnosis: ===================== Chronic Pain Insulin Dependent Diabetes 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 of concern regarding your transplanted liver and possible rejection WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We examined your liver with ultrasound which showed no vasculature problems and with MRCP which showed no changes in your liver bile ducts - We completed a biopsy of your liver which did not show definite rejection. To help protect your liver we increased your Tacrolimus dose to 5mg twice daily. - We treated your abdominal pain with your home medication. - 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]
[]
[ "I129", "E1122", "N189", "Z87891", "K5900" ]
[ "R945: Abnormal results of liver function studies", "Z944: Liver transplant status", "Z85528: Personal history of other malignant neoplasm of kidney", "Z8505: Personal history of malignant neoplasm of liver", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z87891: Personal history of nicotine dependence", "Z905: Acquired absence of kidney", "K5900: Constipation, unspecified", "Z8619: Personal history of other infectious and parasitic diseases", "R1012: Left upper quadrant pain" ]
10,055,729
20,864,666
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with h/o RCC s/p L nephrectomy (___), T2DM, HCV cirrhosis (MELD 22 [elevated INR on Coumadin]) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA (___) and SMV/PV thrombosis (on Coumadin) who presents for DDLT. Briefly, patient was recently admitted for potential DDLT on ___, but was subsequently discharged after it was determined that the donor liver was mismatched in size. Since discharge, he reports having no complaints of infectious symptoms and denies any abdominal pain, N/V/D, abdominal pain, CP/SOB, dysuria, joint pains, new rashes. He continues to take Coumadin for his h/o SMV/PV thrombus and took his last dose yesterday evening. His last PO intake was at 7AM this morning. He now presents for preoperative evaluation regarding possible deceased donor liver transplantation this evening. Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion (___) with no new e/o disease on ___ MRI - h/o SMV/PV thrombosis (dx'd ___ on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC (___) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW (___) - h/o L inguinal hernia repair (age ___ Social History: ___ Family History: ___: no h/o cirrhosis/malignancy Physical Exam: Admission Physical Exam: Vitals: 98.1 54 114/47 18 99% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, large well healed vertical midline incision extending from xiphoid to infra-umbilical region, prior ostomy takedown sites in R and L abdomen, no obvious incisional hernias, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Discharge Physical Exam: Vitals: 97.7 575 144/73 18 98% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, large well healed vertical midline incision extending from xiphoid to infra-umbilical region, prior ostomy takedown sites in R and L abdomen, no obvious incisional hernias, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Pertinent Results: Labs: CBC: 5.0>11.7/37.7<87 Chem 10: 142 | 104 | 32 AGap=11 ---------------<106 4.4 | 27 | 1.5 (baseline Cr ~1.3) Ca: 9.1 Mg: 1.9 P: 3.5 LFTs: ALT: 17 AST: 22 AP: 71 Tbili: 0.4 Alb: 3.7 Coags: ___: 29.8 PTT: 27.9 INR: 2.8 Fibrinogen: 342 UA: negative for blood, nitrites, leukocyte esterase Microbiology: ___ UCx - pending Imaging: ___ CXR: IMPRESSION: No acute cardiopulmonary process. EKG: NSR, no evidence of myocardial ischemia Brief Hospital Course: Mr. ___ was admitted to the Transplant Surgery Service to undergo preoperative clearance for potential deceased donor liver transplant. He was deemed to be an appropriate candidate for transplantation at this time. However, it was noted during organ procurement that the donor liver appeared steatotic and slightly fibrotic (donor with reported h/o prior EtOH use disorder). Thus, the donor organ was deemed a non-viable option for liver transplantation. The patient was thus informed and subsequently discharged on the same medication regimen being followed prior to admission. He is aware that he continues to remain on the liver transplant recipient list going forward. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 2. Allopurinol ___ mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 13. ___ (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. protein 1 oz oral QHS 18. vitamin A and D 1 apply topical QHS 19. Vitamin D ___ UNIT PO ONCE PER MONTH 20. Warfarin 6.5 mg PO 3X/WEEK (___) 21. Warfarin 5 mg PO 4X/WEEK (___) 22. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Discharge Medications: 1. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 2. Allopurinol ___ mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 13. ___ (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. protein 1 oz oral QHS 19. vitamin A and D 1 apply topical QHS 20. Vitamin D ___ UNIT PO ONCE PER MONTH 21. Warfarin 6.5 mg PO 3X/WEEK (___) 22. Warfarin 5 mg PO 4X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: - HCV cirrhosis - h/o PV and SMV thrombosis on coumadin 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 Transplant Surgery Service for preoperative evaluation for deceased donor liver transplant. Unfortunately, the donor liver was deemed not a viable option for transplantation because of diffuse fatty changes and concern for poor organ function. You will continue to remain on the liver transplant candidacy list. As such, you are now ready to be discharged. Please be sure to keep your follow up appointments and continue your medications as prescribed. Do not hesitate to contact the Transplant Surgery coordinators with any questions or concerns. Thank you for allowing us to participate in your care! Sincerely, ___ Transplant Surgery Followup Instructions: ___
[ "K7469", "B1920", "Z5309", "E119", "Z794", "E669", "Z6837", "Z86718", "Z7901", "Z85528", "Z905", "Z87891" ]
Allergies: Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] with h/o RCC s/p L nephrectomy ([MASKED]), T2DM, HCV cirrhosis (MELD 22 [elevated INR on Coumadin]) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ([MASKED]) and SMV/PV thrombosis (on Coumadin) who presents for DDLT. Briefly, patient was recently admitted for potential DDLT on [MASKED], but was subsequently discharged after it was determined that the donor liver was mismatched in size. Since discharge, he reports having no complaints of infectious symptoms and denies any abdominal pain, N/V/D, abdominal pain, CP/SOB, dysuria, joint pains, new rashes. He continues to take Coumadin for his h/o SMV/PV thrombus and took his last dose yesterday evening. His last PO intake was at 7AM this morning. He now presents for preoperative evaluation regarding possible deceased donor liver transplantation this evening. Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion ([MASKED]) with no new e/o disease on [MASKED] MRI - h/o SMV/PV thrombosis (dx'd [MASKED] on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC ([MASKED]) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW ([MASKED]) - h/o L inguinal hernia repair (age [MASKED] Social History: [MASKED] Family History: [MASKED]: no h/o cirrhosis/malignancy Physical Exam: Admission Physical Exam: Vitals: 98.1 54 114/47 18 99% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, large well healed vertical midline incision extending from xiphoid to infra-umbilical region, prior ostomy takedown sites in R and L abdomen, no obvious incisional hernias, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Discharge Physical Exam: Vitals: 97.7 575 144/73 18 98% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, large well healed vertical midline incision extending from xiphoid to infra-umbilical region, prior ostomy takedown sites in R and L abdomen, no obvious incisional hernias, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Pertinent Results: Labs: CBC: 5.0>11.7/37.7<87 Chem 10: 142 | 104 | 32 AGap=11 ---------------<106 4.4 | 27 | 1.5 (baseline Cr ~1.3) Ca: 9.1 Mg: 1.9 P: 3.5 LFTs: ALT: 17 AST: 22 AP: 71 Tbili: 0.4 Alb: 3.7 Coags: [MASKED]: 29.8 PTT: 27.9 INR: 2.8 Fibrinogen: 342 UA: negative for blood, nitrites, leukocyte esterase Microbiology: [MASKED] UCx - pending Imaging: [MASKED] CXR: IMPRESSION: No acute cardiopulmonary process. EKG: NSR, no evidence of myocardial ischemia Brief Hospital Course: Mr. [MASKED] was admitted to the Transplant Surgery Service to undergo preoperative clearance for potential deceased donor liver transplant. He was deemed to be an appropriate candidate for transplantation at this time. However, it was noted during organ procurement that the donor liver appeared steatotic and slightly fibrotic (donor with reported h/o prior EtOH use disorder). Thus, the donor organ was deemed a non-viable option for liver transplantation. The patient was thus informed and subsequently discharged on the same medication regimen being followed prior to admission. He is aware that he continues to remain on the liver transplant recipient list going forward. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 2. Allopurinol [MASKED] mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 13. [MASKED] (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. protein 1 oz oral QHS 18. vitamin A and D 1 apply topical QHS 19. Vitamin D [MASKED] UNIT PO ONCE PER MONTH 20. Warfarin 6.5 mg PO 3X/WEEK ([MASKED]) 21. Warfarin 5 mg PO 4X/WEEK ([MASKED]) 22. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Discharge Medications: 1. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 2. Allopurinol [MASKED] mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 13. [MASKED] (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. protein 1 oz oral QHS 19. vitamin A and D 1 apply topical QHS 20. Vitamin D [MASKED] UNIT PO ONCE PER MONTH 21. Warfarin 6.5 mg PO 3X/WEEK ([MASKED]) 22. Warfarin 5 mg PO 4X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: - HCV cirrhosis - h/o PV and SMV thrombosis on coumadin 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 Transplant Surgery Service for preoperative evaluation for deceased donor liver transplant. Unfortunately, the donor liver was deemed not a viable option for transplantation because of diffuse fatty changes and concern for poor organ function. You will continue to remain on the liver transplant candidacy list. As such, you are now ready to be discharged. Please be sure to keep your follow up appointments and continue your medications as prescribed. Do not hesitate to contact the Transplant Surgery coordinators with any questions or concerns. Thank you for allowing us to participate in your care! Sincerely, [MASKED] Transplant Surgery Followup Instructions: [MASKED]
[]
[ "E119", "Z794", "E669", "Z86718", "Z7901", "Z87891" ]
[ "K7469: Other cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z5309: Procedure and treatment not carried out because of other contraindication", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z85528: Personal history of other malignant neoplasm of kidney", "Z905: Acquired absence of kidney", "Z87891: Personal history of nicotine dependence" ]
10,055,729
22,808,877
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: History of RCC s/p nephrectomy, ___ admitted for liver transplant Major Surgical or Invasive Procedure: ___: Deceased donor liver transplant using piggyback technique, Temporary portacaval shunt, Donor iliac artery conduit from supraceliac aorta to hepatic artery. . ___: Exploration status post liver transplant, liver biopsy, closure of open abdomen. . ___: Reopening of recent laparotomy, evacuation of intra-abdominal hematoma, abdominal washout, right chest tube placement. History of Present Illness: Mr. ___ is a ___ with h/o RCC s/p L nephrectomy (___), T2DM, HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, ___ s/p RFA (___) and SMV/PV thrombosis (on Coumadin) who presents for DDLT. Briefly, patient was recently admitted for potential DDLT on ___ and ___, but was subsequently discharged back to prison after it was determined that the donor livers were mismatched in size on ___ and too steatotic ___ EtOH use on ___. Pt reports no acute changes/new symptoms since his last admission. -will show up at 11AM; OR at 1PM -on warfarin for PVT (INR ___ BMI 36.9) -DDLT (brain death) not high risk ROS: (+) per HPI (-) Denies pain, fevers, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion (___) with no new e/o disease on ___ MRI - h/o SMV/PV thrombosis (dx'd ___ on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC (___) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW (___) - h/o L inguinal hernia repair (age ___ Social History: ___ Family History: no h/o cirrhosis/malignancy Physical Exam: 24 HR Data (last updated ___ @ 2325) Temp: 98.4 (Tm 98.6), BP: 118/73 (118-136/73-88), HR: 96 (89-102), RR: 18, O2 sat: 92% (92-96), O2 delivery: Ra, Wt: 278.9 lb/126.51 kg Fluid Balance (last updated ___ @ 2224) Last 8 hours Total cumulative -640ml IN: Total 0ml OUT: Total 640ml, Urine Amt 625ml, JP R 15ml Last 24 hours Total cumulative -548ml IN: Total 1667ml, PO Amt 1080ml, TF/Flush Amt 587ml OUT: Total 2215ml, Urine Amt 2200ml, JP R 15ml Gen: A&Ox3, comfortable-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: comfortable on room air CV: NRRR, no m/r/g Abd: soft, mildly distended, TTP throughout abdomen diffusely Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Pertinent Results: Labs on Admission: ___ WBC-4.8 RBC-4.58* Hgb-12.5* Hct-38.7* MCV-85 MCH-27.3 MCHC-32.3 RDW-14.3 RDWSD-43.7 Plt ___ PTT-48.3* ___ Glucose-129* UreaN-34* Creat-1.5* Na-140 K-4.6 Cl-102 HCO3-25 AnGap-13 ALT-18 AST-24 AlkPhos-74 TotBili-0.4 Albumin-3.8 Calcium-9.0 Phos-2.9 Mg-1.9 Triglyc-143 HDL-33* CHOL/HD-2.9 LDLcalc-35 HCV VL-NOT DETECT . Labs at Discharge: ___ WBC-8.8 RBC-2.86* Hgb-8.4* Hct-26.2* MCV-92 MCH-29.4 MCHC-32.1 RDW-17.3* RDWSD-58.5* Plt ___ PTT-24.0* ___ Glucose-108* UreaN-48* Creat-1.5* Na-132* K-5.3 Cl-95* HCO3-27 AnGap-10 ALT-45* AST-47* AlkPhos-427* TotBili-1.7* tacroFK-8.6 Brief Hospital Course: On ___ he underwent DDLT. The operation was notable for a difficult arterial anastamosis, requiring supra-celiac aorta to donor hepatic artery bypass with iliac artery graft. He was left open with ABThera in place as well as three drains, and taken to the SICU. He was maintained on bleeding pathway and received significant blood products to correct coagulopathy and ongoing blood loss. On POD#1 there was concern for limited neurologic exam; ___ showed no acute infarct or bleed. He had continued bleeding and was taken back to the operating room on POD#1 for exploration. No active bleed was identified and his abdomen was closed. He remained on bleeding pathway. CRRT was initiated for ___ and oliguria. He had ongoing transfusion requirements and coagulopathy that were not corrected with transfusions and decision was made to take him back to the operating room for re-exploration. He was taken back to the operating room on ___ for re-exploration, found to have hematoma but no evidence of active bleed. Chest tube was placed for monitoring. He was washed out and abdomen was closed. He continued on CVVH, with minimal pressor requirement to allow for aggressive diuresis. Tube feeds were initiated on ___. He was extubated on ___. He received 48 hours of antibiotics from ___ for leukocytosis and low-grade fever; work-up was without source and antibiotics were discontinued. Post-extubation the patient had a significant narcotic requirement for pain control, in the setting of chronic narcotic use. The chest tube was removed on ___ with post-pull CXR showing no evidence of pneumothorax. He was diuresed down to admission weight and had improvement in his ___ and urine output and CVVH was discontinued on ___. On ___ he was cleared by S&S for PO medications and thin liquids, diet was advanced as tolerated. He was transferred to the floor on POD8. . Induction immunosuppression for liver transplant included Mycophenolate 1 gram pre op and continued at 1 gram Twice a day with good tolerance. Solumedrol 500 mg was given in the initial OR and followed the solumedrol to PO steroid taper. Of note, 1 week of prednisone at 17.5 was decreased down to 15 mg (so taper accelerated by one week) for mental status concerns. He received 3 doses of Simulect around time of the surgeries to help with kidney function and provide immunosuppression. Tacro was started on the morning of POD 8, with daily levels and dosage adjusted per level. Tacro level was 8.6 on day of discharge with 3 mg twice a day as recommended dose. . Once the patient was on the regular surgical floor, he continued tube feeds until fully cleared for regular diet and intake was verified. He was continuing to make ___ liters of urine daily and creatinine returned to admission level of 1.5 by day of discharge. LFTs and coagulation profiles were normalizing. Of note there was a mild increase in T bili and alk phos just before discharge, these will be followed up in transplant clinic. . Patient mental status was clearing. He was having difficulty with pain management, and long acting in addition to oxycodone were used with fair benefit. He was ambulating, having bowel movements, tolerating a regular diet. He will be transferred back to ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous GLUCONATE 324 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 4. Lactulose 15 mL PO DAILY 5. morphine 20 mg oral DAILY:PRN 6. Nadolol 40 mg PO DAILY 7. nutritional supplement-caloric 1 ounce oral QHS 8. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 9. Omeprazole 20 mg PO DAILY 10. vitamin A and D topical QHS 11. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 12. Warfarin 6.5 mg PO 3X/WEEK (___) 13. Warfarin 5 mg PO 4X/WEEK (___) 14. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 15. amLODIPine 10 mg PO DAILY 16. Allopurinol ___ mg PO DAILY 17. Amitriptyline 50 mg PO QHS 18. Aspirin 81 mg PO DAILY 19. Atorvastatin 20 mg PO QPM 20. Docusate Sodium 100 mg PO BID 21. Doxazosin 4 mg PO HS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Maximum 2 grams daily 2. Fluconazole 400 mg PO Q24H 3. Fludrocortisone Acetate 0.1 mg PO DAILY 4. Gabapentin 100 mg PO BID Do not stop abruptly 5. Metoprolol Tartrate 12.5 mg PO BID 6. Mycophenolate Mofetil 1000 mg PO BID 7. PredniSONE 15 mg PO DAILY Duration: 7 Doses Follow Taper 8. QUEtiapine Fumarate 100 mg PO QHS 9. Senna 8.6 mg PO QHS Discontinue if diarrhea or multiple BMs daily 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Tacrolimus 3 mg PO Q12H 12. ValGANCIclovir 900 mg PO Q24H 13. Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. vitamin A and D 1 application topical QHS 15. Allopurinol ___ mg PO DAILY 16. Aspirin 81 mg PO DAILY 17. Docusate Sodium 100 mg PO BID 18. Doxazosin 4 mg PO HS 19. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 20. morphine 20 mg oral DAILY:PRN pain management 21. Omeprazole 20 mg PO DAILY 22. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 23. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 24. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until Instructed by transplant clinic Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: History of RCC, HCV cirrhosis now s/p liver transplant Acute Kidney Injury Intra-abdominal hematoma requiring laparotomy Pre-existing DM 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient to return to ___ Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring your list of current medications to every clinic visit. . You will have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, T Bili, Trough Tacro level, Urinalysis. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples are removed approximately 3 weeks following your transplant. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. . Check your blood pressure daily. Report consistently elevated values above 160 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Followup Instructions: ___
[ "B182", "N170", "J95821", "K766", "C220", "D62", "D684", "K91870", "F05", "K9161", "J9572", "K660", "E669", "Y830", "E8770", "Y92230", "Y92234", "I129", "N189", "E876", "E1165", "R509", "D72829", "G8929", "Z794", "Z905", "E1122", "Z85528", "Z86718", "Z7901", "Z9049", "Z87891", "Z781", "Z6837" ]
Allergies: Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: History of RCC s/p nephrectomy, [MASKED] admitted for liver transplant Major Surgical or Invasive Procedure: [MASKED]: Deceased donor liver transplant using piggyback technique, Temporary portacaval shunt, Donor iliac artery conduit from supraceliac aorta to hepatic artery. . [MASKED]: Exploration status post liver transplant, liver biopsy, closure of open abdomen. . [MASKED]: Reopening of recent laparotomy, evacuation of intra-abdominal hematoma, abdominal washout, right chest tube placement. History of Present Illness: Mr. [MASKED] is a [MASKED] with h/o RCC s/p L nephrectomy ([MASKED]), T2DM, HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, [MASKED] s/p RFA ([MASKED]) and SMV/PV thrombosis (on Coumadin) who presents for DDLT. Briefly, patient was recently admitted for potential DDLT on [MASKED] and [MASKED], but was subsequently discharged back to prison after it was determined that the donor livers were mismatched in size on [MASKED] and too steatotic [MASKED] EtOH use on [MASKED]. Pt reports no acute changes/new symptoms since his last admission. -will show up at 11AM; OR at 1PM -on warfarin for PVT (INR [MASKED] BMI 36.9) -DDLT (brain death) not high risk ROS: (+) per HPI (-) Denies pain, fevers, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion ([MASKED]) with no new e/o disease on [MASKED] MRI - h/o SMV/PV thrombosis (dx'd [MASKED] on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC ([MASKED]) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW ([MASKED]) - h/o L inguinal hernia repair (age [MASKED] Social History: [MASKED] Family History: no h/o cirrhosis/malignancy Physical Exam: 24 HR Data (last updated [MASKED] @ 2325) Temp: 98.4 (Tm 98.6), BP: 118/73 (118-136/73-88), HR: 96 (89-102), RR: 18, O2 sat: 92% (92-96), O2 delivery: Ra, Wt: 278.9 lb/126.51 kg Fluid Balance (last updated [MASKED] @ 2224) Last 8 hours Total cumulative -640ml IN: Total 0ml OUT: Total 640ml, Urine Amt 625ml, JP R 15ml Last 24 hours Total cumulative -548ml IN: Total 1667ml, PO Amt 1080ml, TF/Flush Amt 587ml OUT: Total 2215ml, Urine Amt 2200ml, JP R 15ml Gen: A&Ox3, comfortable-appearing male, in NAD HEENT: No scleral icterus, no palpable LAD Pulm: comfortable on room air CV: NRRR, no m/r/g Abd: soft, mildly distended, TTP throughout abdomen diffusely Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Pertinent Results: Labs on Admission: [MASKED] WBC-4.8 RBC-4.58* Hgb-12.5* Hct-38.7* MCV-85 MCH-27.3 MCHC-32.3 RDW-14.3 RDWSD-43.7 Plt [MASKED] PTT-48.3* [MASKED] Glucose-129* UreaN-34* Creat-1.5* Na-140 K-4.6 Cl-102 HCO3-25 AnGap-13 ALT-18 AST-24 AlkPhos-74 TotBili-0.4 Albumin-3.8 Calcium-9.0 Phos-2.9 Mg-1.9 Triglyc-143 HDL-33* CHOL/HD-2.9 LDLcalc-35 HCV VL-NOT DETECT . Labs at Discharge: [MASKED] WBC-8.8 RBC-2.86* Hgb-8.4* Hct-26.2* MCV-92 MCH-29.4 MCHC-32.1 RDW-17.3* RDWSD-58.5* Plt [MASKED] PTT-24.0* [MASKED] Glucose-108* UreaN-48* Creat-1.5* Na-132* K-5.3 Cl-95* HCO3-27 AnGap-10 ALT-45* AST-47* AlkPhos-427* TotBili-1.7* tacroFK-8.6 Brief Hospital Course: On [MASKED] he underwent DDLT. The operation was notable for a difficult arterial anastamosis, requiring supra-celiac aorta to donor hepatic artery bypass with iliac artery graft. He was left open with ABThera in place as well as three drains, and taken to the SICU. He was maintained on bleeding pathway and received significant blood products to correct coagulopathy and ongoing blood loss. On POD#1 there was concern for limited neurologic exam; [MASKED] showed no acute infarct or bleed. He had continued bleeding and was taken back to the operating room on POD#1 for exploration. No active bleed was identified and his abdomen was closed. He remained on bleeding pathway. CRRT was initiated for [MASKED] and oliguria. He had ongoing transfusion requirements and coagulopathy that were not corrected with transfusions and decision was made to take him back to the operating room for re-exploration. He was taken back to the operating room on [MASKED] for re-exploration, found to have hematoma but no evidence of active bleed. Chest tube was placed for monitoring. He was washed out and abdomen was closed. He continued on CVVH, with minimal pressor requirement to allow for aggressive diuresis. Tube feeds were initiated on [MASKED]. He was extubated on [MASKED]. He received 48 hours of antibiotics from [MASKED] for leukocytosis and low-grade fever; work-up was without source and antibiotics were discontinued. Post-extubation the patient had a significant narcotic requirement for pain control, in the setting of chronic narcotic use. The chest tube was removed on [MASKED] with post-pull CXR showing no evidence of pneumothorax. He was diuresed down to admission weight and had improvement in his [MASKED] and urine output and CVVH was discontinued on [MASKED]. On [MASKED] he was cleared by S&S for PO medications and thin liquids, diet was advanced as tolerated. He was transferred to the floor on POD8. . Induction immunosuppression for liver transplant included Mycophenolate 1 gram pre op and continued at 1 gram Twice a day with good tolerance. Solumedrol 500 mg was given in the initial OR and followed the solumedrol to PO steroid taper. Of note, 1 week of prednisone at 17.5 was decreased down to 15 mg (so taper accelerated by one week) for mental status concerns. He received 3 doses of Simulect around time of the surgeries to help with kidney function and provide immunosuppression. Tacro was started on the morning of POD 8, with daily levels and dosage adjusted per level. Tacro level was 8.6 on day of discharge with 3 mg twice a day as recommended dose. . Once the patient was on the regular surgical floor, he continued tube feeds until fully cleared for regular diet and intake was verified. He was continuing to make [MASKED] liters of urine daily and creatinine returned to admission level of 1.5 by day of discharge. LFTs and coagulation profiles were normalizing. Of note there was a mild increase in T bili and alk phos just before discharge, these will be followed up in transplant clinic. . Patient mental status was clearing. He was having difficulty with pain management, and long acting in addition to oxycodone were used with fair benefit. He was ambulating, having bowel movements, tolerating a regular diet. He will be transferred back to [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous GLUCONATE 324 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 4. Lactulose 15 mL PO DAILY 5. morphine 20 mg oral DAILY:PRN 6. Nadolol 40 mg PO DAILY 7. nutritional supplement-caloric 1 ounce oral QHS 8. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 9. Omeprazole 20 mg PO DAILY 10. vitamin A and D topical QHS 11. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) 12. Warfarin 6.5 mg PO 3X/WEEK ([MASKED]) 13. Warfarin 5 mg PO 4X/WEEK ([MASKED]) 14. NPH 14 Units Breakfast NPH 15 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 15. amLODIPine 10 mg PO DAILY 16. Allopurinol [MASKED] mg PO DAILY 17. Amitriptyline 50 mg PO QHS 18. Aspirin 81 mg PO DAILY 19. Atorvastatin 20 mg PO QPM 20. Docusate Sodium 100 mg PO BID 21. Doxazosin 4 mg PO HS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Maximum 2 grams daily 2. Fluconazole 400 mg PO Q24H 3. Fludrocortisone Acetate 0.1 mg PO DAILY 4. Gabapentin 100 mg PO BID Do not stop abruptly 5. Metoprolol Tartrate 12.5 mg PO BID 6. Mycophenolate Mofetil 1000 mg PO BID 7. PredniSONE 15 mg PO DAILY Duration: 7 Doses Follow Taper 8. QUEtiapine Fumarate 100 mg PO QHS 9. Senna 8.6 mg PO QHS Discontinue if diarrhea or multiple BMs daily 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Tacrolimus 3 mg PO Q12H 12. ValGANCIclovir 900 mg PO Q24H 13. Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner NPH 22 Units Breakfast NPH 22 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. vitamin A and D 1 application topical QHS 15. Allopurinol [MASKED] mg PO DAILY 16. Aspirin 81 mg PO DAILY 17. Docusate Sodium 100 mg PO BID 18. Doxazosin 4 mg PO HS 19. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 20. morphine 20 mg oral DAILY:PRN pain management 21. Omeprazole 20 mg PO DAILY 22. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 23. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) 24. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until Instructed by transplant clinic Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: History of RCC, HCV cirrhosis now s/p liver transplant Acute Kidney Injury Intra-abdominal hematoma requiring laparotomy Pre-existing DM 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient to return to [MASKED] Please call the transplant clinic at [MASKED] for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring your list of current medications to every clinic visit. . You will have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax [MASKED] . CBC, Chem 10, AST, T Bili, Trough Tacro level, Urinalysis. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples are removed approximately 3 weeks following your transplant. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. . Check your blood pressure daily. Report consistently elevated values above 160 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at [MASKED]. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Followup Instructions: [MASKED]
[]
[ "D62", "E669", "Y92230", "I129", "N189", "E1165", "G8929", "Z794", "E1122", "Z86718", "Z7901", "Z87891" ]
[ "B182: Chronic viral hepatitis C", "N170: Acute kidney failure with tubular necrosis", "J95821: Acute postprocedural respiratory failure", "K766: Portal hypertension", "C220: Liver cell carcinoma", "D62: Acute posthemorrhagic anemia", "D684: Acquired coagulation factor deficiency", "K91870: Postprocedural hematoma of a digestive system organ or structure following a digestive system procedure", "F05: Delirium due to known physiological condition", "K9161: Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure", "J9572: Accidental puncture and laceration of a respiratory system organ or structure during other procedure", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "E669: Obesity, unspecified", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E8770: Fluid overload, unspecified", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E876: Hypokalemia", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R509: Fever, unspecified", "D72829: Elevated white blood cell count, unspecified", "G8929: Other chronic pain", "Z794: Long term (current) use of insulin", "Z905: Acquired absence of kidney", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z85528: Personal history of other malignant neoplasm of kidney", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z9049: Acquired absence of other specified parts of digestive tract", "Z87891: Personal history of nicotine dependence", "Z781: Physical restraint status", "Z6837: Body mass index [BMI] 37.0-37.9, adult" ]
10,055,729
23,567,943
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Possible DDLT Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o HCV Child's class B9 cirrhosis c/b HCC in segment VIII s/p RFA (___) now presenting for DDLT. Hep C eradicated with treatment. MELD score 21 as of ___ driven primarily by Coumadin. MELD exception points of 34 as of ___. On coumadin for portal and mesenteric vein thrombosis. Portal hypertension with edema complicated by hepatic encephalopathy and ascites, well controlled on home diuretics. Hx chronic pain on chronic pain medications. Insulin dependent diabetes. Hep C viral load nondectable as of ___. Patient feels well today, no complaints. He notes chronic R leg pain from mid thigh to knee unchanged from baseline. He also notes baseline b/l leg edema unchanged from baseline, as well as easy brusability which he attributes to his Coumadin therapy. Past Medical History: Past medical and surgical history -Hepatitis C, status post treatment, cirrhosis, renal cell cancer status post L nephrectomy ___ -HCC one lesion of 3 cm, status post RFA -diabetes on insulin -Laparotomy with temporary colostomy for a gunshot wound in ___. He has had remote repair of a left inguinal hernia. -HTN Social History: ___ Family History: Denies past family medical history Physical Exam: VS: ___ 1158 Temp: 98.0 PO BP: 115/79 L Sitting HR: 55 RR: 18 O2 sat: 98% O2 delivery: Ra ___ 1223 FSBG: 78 Gen: NAD, alert and awake HEENT: AT/NC, PERRLA, MMM, oropharynx clear, neck supple Resp: CTAB, no wheezing, rales or ronchi CV: RRR, no m//r/g GI: soft, NTND. Multiple scars in midline and b/l from prior L nephrectomy and colostomy Ext: WWF, trace b/l ___ edema Neuro: moving all extremeties Brief Hospital Course: The patient was admitted to the hospital after being called in for a potential deceased donor liver transplant. The patient did not get the offer of the liver and is ready to be discharged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Allopurinol ___ mg PO BID 3. Amitriptyline 50 mg PO QHS 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Doxazosin 4 mg PO HS 8. Ferrous GLUCONATE 324 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 12. Lactulose 15 mL PO DAILY 13. ___ (morphine) 20 mg oral DAILY:PRN 14. Nadolol 40 mg PO DAILY 15. protein 1 oz oral QHS 16. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 17. Omeprazole 20 mg PO DAILY 18. vitamin A and D 1 apply topical QHS 19. Vitamin D ___ UNIT PO ONCE PER MONTH 20. Warfarin 6.5 mg PO 3X/WEEK (___) 21. Warfarin 5 mg PO 4X/WEEK (___) 22. NPH 14 Units Breakfast NPH 15 Units Dinner Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Discharge Medications: 1. NPH 14 Units Breakfast NPH 15 Units Dinner Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 2. Allopurinol ___ mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 13. ___ (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. protein 1 oz oral QHS 19. vitamin A and D 1 apply topical QHS 20. Vitamin D ___ UNIT PO ONCE PER MONTH 21. Warfarin 6.5 mg PO 3X/WEEK (___) 22. Warfarin 5 mg PO 4X/WEEK (___) Discharge Disposition: Extended Care Discharge Diagnosis: 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 pleasure taking care of you at ___ ___. You were admitted to the hospital for potential liver transplant. Unfortunately you were unable to receive the liver transplant and is now ready to be discharged. Followup Instructions: ___
[ "K7460", "I8510", "Z8505", "K8020", "Z7682", "Z538", "Z905", "I81", "K766", "K7290", "R188", "K862", "Z87891", "Z7901", "Z85528", "E119", "I10", "M79604", "G8929", "Z8619" ]
Allergies: Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: Possible DDLT Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with h/o HCV Child's class B9 cirrhosis c/b HCC in segment VIII s/p RFA ([MASKED]) now presenting for DDLT. Hep C eradicated with treatment. MELD score 21 as of [MASKED] driven primarily by Coumadin. MELD exception points of 34 as of [MASKED]. On coumadin for portal and mesenteric vein thrombosis. Portal hypertension with edema complicated by hepatic encephalopathy and ascites, well controlled on home diuretics. Hx chronic pain on chronic pain medications. Insulin dependent diabetes. Hep C viral load nondectable as of [MASKED]. Patient feels well today, no complaints. He notes chronic R leg pain from mid thigh to knee unchanged from baseline. He also notes baseline b/l leg edema unchanged from baseline, as well as easy brusability which he attributes to his Coumadin therapy. Past Medical History: Past medical and surgical history -Hepatitis C, status post treatment, cirrhosis, renal cell cancer status post L nephrectomy [MASKED] -HCC one lesion of 3 cm, status post RFA -diabetes on insulin -Laparotomy with temporary colostomy for a gunshot wound in [MASKED]. He has had remote repair of a left inguinal hernia. -HTN Social History: [MASKED] Family History: Denies past family medical history Physical Exam: VS: [MASKED] 1158 Temp: 98.0 PO BP: 115/79 L Sitting HR: 55 RR: 18 O2 sat: 98% O2 delivery: Ra [MASKED] 1223 FSBG: 78 Gen: NAD, alert and awake HEENT: AT/NC, PERRLA, MMM, oropharynx clear, neck supple Resp: CTAB, no wheezing, rales or ronchi CV: RRR, no m//r/g GI: soft, NTND. Multiple scars in midline and b/l from prior L nephrectomy and colostomy Ext: WWF, trace b/l [MASKED] edema Neuro: moving all extremeties Brief Hospital Course: The patient was admitted to the hospital after being called in for a potential deceased donor liver transplant. The patient did not get the offer of the liver and is ready to be discharged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Allopurinol [MASKED] mg PO BID 3. Amitriptyline 50 mg PO QHS 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Doxazosin 4 mg PO HS 8. Ferrous GLUCONATE 324 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 11. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 12. Lactulose 15 mL PO DAILY 13. [MASKED] (morphine) 20 mg oral DAILY:PRN 14. Nadolol 40 mg PO DAILY 15. protein 1 oz oral QHS 16. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 17. Omeprazole 20 mg PO DAILY 18. vitamin A and D 1 apply topical QHS 19. Vitamin D [MASKED] UNIT PO ONCE PER MONTH 20. Warfarin 6.5 mg PO 3X/WEEK ([MASKED]) 21. Warfarin 5 mg PO 4X/WEEK ([MASKED]) 22. NPH 14 Units Breakfast NPH 15 Units Dinner Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Discharge Medications: 1. NPH 14 Units Breakfast NPH 15 Units Dinner Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner 2. Allopurinol [MASKED] mg PO BID 3. Amitriptyline 50 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Doxazosin 4 mg PO HS 9. Ferrous GLUCONATE 324 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Glucose Tab 4 TAB PO DAILY:PRN low blood sugar 12. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 13. [MASKED] (morphine) 20 mg oral DAILY:PRN 14. Lactulose 15 mL PO DAILY 15. Nadolol 40 mg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. protein 1 oz oral QHS 19. vitamin A and D 1 apply topical QHS 20. Vitamin D [MASKED] UNIT PO ONCE PER MONTH 21. Warfarin 6.5 mg PO 3X/WEEK ([MASKED]) 22. Warfarin 5 mg PO 4X/WEEK ([MASKED]) Discharge Disposition: Extended Care Discharge Diagnosis: 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 pleasure taking care of you at [MASKED] [MASKED]. You were admitted to the hospital for potential liver transplant. Unfortunately you were unable to receive the liver transplant and is now ready to be discharged. Followup Instructions: [MASKED]
[]
[ "Z87891", "Z7901", "E119", "I10", "G8929" ]
[ "K7460: Unspecified cirrhosis of liver", "I8510: Secondary esophageal varices without bleeding", "Z8505: Personal history of malignant neoplasm of liver", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "Z7682: Awaiting organ transplant status", "Z538: Procedure and treatment not carried out for other reasons", "Z905: Acquired absence of kidney", "I81: Portal vein thrombosis", "K766: Portal hypertension", "K7290: Hepatic failure, unspecified without coma", "R188: Other ascites", "K862: Cyst of pancreas", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "Z85528: Personal history of other malignant neoplasm of kidney", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "M79604: Pain in right leg", "G8929: Other chronic pain", "Z8619: Personal history of other infectious and parasitic diseases" ]
10,055,729
27,856,085
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: ERCP ith sphincterotomy and stent placement History of Present Illness: ___ with h/o RCC s/p L nephrectomy (___), T2DM, HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA (___) and SMV/PV thrombosis (on Coumadin) s/p DDLT in ___ who presents for monitoring post-ERCP. He had abnormal LFTs post-transplant which prompted MRCP for further evaluation. MRCP showed stricture at the biliary anastomosis, with dilation of the extrahepatic biliary tree both above and below the anastomosis. Today he underwent ERCP for stenting. Per the report the cannulation was very difficult and required precut sphincterotomy. A 0.2cm benign appearing stricture at the mid-CBD was noted and a stent was placed. On arrival to the floor he was reporting some ___ abdominal pain. He was quite upset that he needed to remain NPO overnight and was requesting his transplant meds since he was told it was very important to be timely with his medications Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion (___) with no new e/o disease on ___ MRI - h/o SMV/PV thrombosis (dx'd ___ on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC (___) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW (___) - h/o L inguinal hernia repair (age ___ Social History: ___ Family History: no h/o cirrhosis/malignancy Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.3F, 146/78, HR89RR20 97%Ra GENERAL: Alert and interactive. In no acute distress HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, tender to palpation right upper quadrant, otherwise non-tender. Several recent surgical scars present EXTREMITIES: No edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: Pertinent Results: Post ERCP labs: ___ WBC-4.7 RBC-3.73* Hgb-9.8* Hct-31.4* MCV-84 MCH-26.3 MCHC-31.2* RDW-15.9* RDWSD-47.3* Plt ___ Glucose-83 UreaN-14 Creat-1.0 Na-137 K-4.5 Cl-99 HCO3-24 AnGap-14 ALT-30 AST-41* AlkPhos-297* Amylase-PND TotBili-0.5 Calcium-8.6 Phos-3.3 Mg-1.5* Brief Hospital Course: ___ y/o male from ___ with history of liver transplant on ___ who has been brought in for ERCP, and admitted post procedure for hydration and monitoring. . The patient underwent ERCP with sphincterotomy and stent placement for a biliary stricture. Post procedure he had some abdominal pain but does not have a chemical pancreatitis. Diet was advanced and tolerated. He was voiding Home immunosuppression of Tacro and mycophenolate were continued as well as indicated home medications. We increased his metoprolol to 25mg BID for high blood pressures. He had an episode of emesis which resolved on ___. He was discharged back to ___ with no issues. He will need ERCP follow up in ___ months for repeat ERCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Fluconazole 400 mg PO Q24H 5. Gabapentin 100 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Mycophenolate Mofetil 1000 mg PO BID 8. Senna 8.6 mg PO QHS 9. ValGANCIclovir 900 mg PO Q24H 10. Allopurinol ___ mg PO BID 11. Aspirin 81 mg PO DAILY 12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 13. morphine 20 mg oral DAILY:PRN pain management 14. Omeprazole 20 mg PO DAILY 15. vitamin A and D 1 application topical QHS 16. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 17. Tacrolimus 1 mg PO Q12H 18. Dapsone 100 mg PO DAILY 19. Amitriptyline 25 mg PO QHS 20. NPH 22 Units Breakfast NPH 22 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Insulin SC Sliding Scale using REG Insulin 21. Magnesium Oxide 400 mg PO BID 22. Lactulose 30 mL PO BID Discharge Medications: 1. NPH 22 Units Breakfast NPH 22 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Lactulose 30 mL PO BID:PRN constipation 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Allopurinol ___ mg PO BID 5. Amitriptyline 25 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluconazole 400 mg PO Q24H 10. Gabapentin 100 mg PO BID 11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN internal hemorrhoids 12. Magnesium Oxide 400 mg PO BID 13. Metoprolol Tartrate 12.5 mg PO BID 14. morphine 20 mg oral DAILY:PRN pain management 15. Mycophenolate Mofetil 1000 mg PO BID 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. Senna 8.6 mg PO QHS 19. Tacrolimus 1 mg PO Q12H 20. ValGANCIclovir 900 mg PO Q24H 21. vitamin A and D 1 application topical QHS 22. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) Discharge Disposition: Extended Care Discharge Diagnosis: Biliary stricture History of liver transplant s/p ERCP with sphincterotomy and stent placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring your list of current medications to every clinic visit. . You will have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos T Bili, Trough Tacro level. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples are removed approximately 3 weeks following your transplant. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. Eat small frequent meals, and you may supplement with things like carnation instant breakfast or Ensure. . Check your blood pressure at home. Report consistently elevated values above 160 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Consult transplant binder, and there is always someone on call at the transplant clinic with any questions that may arise Followup Instructions: ___
[ "K9189", "K831", "Y832", "Y929", "K7469", "B942", "Z944", "M109", "K5900", "I10", "G8929", "E1142", "Z794", "K766", "Z7901", "K7290", "E669", "Z6836", "Z86718", "Z85528", "Z87891" ]
Allergies: Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED]: ERCP ith sphincterotomy and stent placement History of Present Illness: [MASKED] with h/o RCC s/p L nephrectomy ([MASKED]), T2DM, HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ([MASKED]) and SMV/PV thrombosis (on Coumadin) s/p DDLT in [MASKED] who presents for monitoring post-ERCP. He had abnormal LFTs post-transplant which prompted MRCP for further evaluation. MRCP showed stricture at the biliary anastomosis, with dilation of the extrahepatic biliary tree both above and below the anastomosis. Today he underwent ERCP for stenting. Per the report the cannulation was very difficult and required precut sphincterotomy. A 0.2cm benign appearing stricture at the mid-CBD was noted and a stent was placed. On arrival to the floor he was reporting some [MASKED] abdominal pain. He was quite upset that he needed to remain NPO overnight and was requesting his transplant meds since he was told it was very important to be timely with his medications Past Medical History: PMH: - HCV cirrhosis (MELD xx) c/b hepatic encephalopathy, portal HTN, HCC s/p RFA ablation of Segment VII/VIII lesion ([MASKED]) with no new e/o disease on [MASKED] MRI - h/o SMV/PV thrombosis (dx'd [MASKED] on Coumadin - h/o RCC s/p resection - T2DM on insulin - obesity PSH: - s/p L nephrectomy for RCC ([MASKED]) - s/p ex-lap, partial colectomy/colostomy and subsequent take down for GSW ([MASKED]) - h/o L inguinal hernia repair (age [MASKED] Social History: [MASKED] Family History: no h/o cirrhosis/malignancy Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.3F, 146/78, HR89RR20 97%Ra GENERAL: Alert and interactive. In no acute distress HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, tender to palpation right upper quadrant, otherwise non-tender. Several recent surgical scars present EXTREMITIES: No edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: Pertinent Results: Post ERCP labs: [MASKED] WBC-4.7 RBC-3.73* Hgb-9.8* Hct-31.4* MCV-84 MCH-26.3 MCHC-31.2* RDW-15.9* RDWSD-47.3* Plt [MASKED] Glucose-83 UreaN-14 Creat-1.0 Na-137 K-4.5 Cl-99 HCO3-24 AnGap-14 ALT-30 AST-41* AlkPhos-297* Amylase-PND TotBili-0.5 Calcium-8.6 Phos-3.3 Mg-1.5* Brief Hospital Course: [MASKED] y/o male from [MASKED] with history of liver transplant on [MASKED] who has been brought in for ERCP, and admitted post procedure for hydration and monitoring. . The patient underwent ERCP with sphincterotomy and stent placement for a biliary stricture. Post procedure he had some abdominal pain but does not have a chemical pancreatitis. Diet was advanced and tolerated. He was voiding Home immunosuppression of Tacro and mycophenolate were continued as well as indicated home medications. We increased his metoprolol to 25mg BID for high blood pressures. He had an episode of emesis which resolved on [MASKED]. He was discharged back to [MASKED] with no issues. He will need ERCP follow up in [MASKED] months for repeat ERCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Fluconazole 400 mg PO Q24H 5. Gabapentin 100 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Mycophenolate Mofetil 1000 mg PO BID 8. Senna 8.6 mg PO QHS 9. ValGANCIclovir 900 mg PO Q24H 10. Allopurinol [MASKED] mg PO BID 11. Aspirin 81 mg PO DAILY 12. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 13. morphine 20 mg oral DAILY:PRN pain management 14. Omeprazole 20 mg PO DAILY 15. vitamin A and D 1 application topical QHS 16. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) 17. Tacrolimus 1 mg PO Q12H 18. Dapsone 100 mg PO DAILY 19. Amitriptyline 25 mg PO QHS 20. NPH 22 Units Breakfast NPH 22 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Insulin SC Sliding Scale using REG Insulin 21. Magnesium Oxide 400 mg PO BID 22. Lactulose 30 mL PO BID Discharge Medications: 1. NPH 22 Units Breakfast NPH 22 Units Bedtime Regular 3 Units Breakfast Regular 3 Units Lunch Regular 3 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Lactulose 30 mL PO BID:PRN constipation 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Allopurinol [MASKED] mg PO BID 5. Amitriptyline 25 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluconazole 400 mg PO Q24H 10. Gabapentin 100 mg PO BID 11. Hydrocortisone (Rectal) 2.5% Cream ID:PRN internal hemorrhoids 12. Magnesium Oxide 400 mg PO BID 13. Metoprolol Tartrate 12.5 mg PO BID 14. morphine 20 mg oral DAILY:PRN pain management 15. Mycophenolate Mofetil 1000 mg PO BID 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Severe 18. Senna 8.6 mg PO QHS 19. Tacrolimus 1 mg PO Q12H 20. ValGANCIclovir 900 mg PO Q24H 21. vitamin A and D 1 application topical QHS 22. Vitamin D [MASKED] UNIT PO EVERY 4 WEEKS (MO) Discharge Disposition: Extended Care Discharge Diagnosis: Biliary stricture History of liver transplant s/p ERCP with sphincterotomy and stent placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at [MASKED] for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring your list of current medications to every clinic visit. . You will have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax [MASKED] . CBC, Chem 10, AST, ALT, Alk Phos T Bili, Trough Tacro level. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples are removed approximately 3 weeks following your transplant. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. Eat small frequent meals, and you may supplement with things like carnation instant breakfast or Ensure. . Check your blood pressure at home. Report consistently elevated values above 160 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at [MASKED]. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Consult transplant binder, and there is always someone on call at the transplant clinic with any questions that may arise Followup Instructions: [MASKED]
[]
[ "Y929", "M109", "K5900", "I10", "G8929", "Z794", "Z7901", "E669", "Z86718", "Z87891" ]
[ "K9189: Other postprocedural complications and disorders of digestive system", "K831: Obstruction of bile duct", "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", "K7469: Other cirrhosis of liver", "B942: Sequelae of viral hepatitis", "Z944: Liver transplant status", "M109: Gout, unspecified", "K5900: Constipation, unspecified", "I10: Essential (primary) hypertension", "G8929: Other chronic pain", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "K766: Portal hypertension", "Z7901: Long term (current) use of anticoagulants", "K7290: Hepatic failure, unspecified without coma", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Z86718: Personal history of other venous thrombosis and embolism", "Z85528: Personal history of other malignant neoplasm of kidney", "Z87891: Personal history of nicotine dependence" ]
10,055,939
26,362,706
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hemothorax Major Surgical or Invasive Procedure: ___ Left VATS, evacuation of hemothorax and partial decortication, bronchoscopy with lavage ___ Bronchoscopy ___ Right PICC placement History of Present Illness: ___ with PMH of smoking for ___ years (quit ___ years ago), COPD, peripheral vascular disease requiring multiple stents, aortic valve disease s/p TAVR procedure (on ASA and Plavix) at the ___ ___ in ___ who presents to ___ from ___ for escalation of care of respiratory distress in the setting of a left-sided hemothorax following thoracentesis performed earlier today. He was having productive yellow sputum, fever, and fatigue for which he was empirically treated with azithromycin. However, he did not improve on the antibiotics and went to the ED for further evaluation. At that time, he underwent a CT scan of the chest which showed pneumonia of the LLL with some cavitation in the LUL as well as a L pleural effusion w/ compressive atelectasis of the LLL of the lung. At that time, he was admitted to the hospital, started on IV antibiotics, and ___ was consulted for thoracentesis. Under ultrasound guidance, a left-sided thoracentesis was performed with removal of purulent fluid which was sent for gram stain, which demonstrated multiple gram-positive and gram-negative organisms. During the procedure, thoracic surgery was consulted and the decision was made to leave a drainage catheter in the left chest as the fluid was grossly purulent on aspiration. However, when returning to place the drainage catheter, the thoracentesis catheter had been dislodged. Under ultrasound guidance, the fluid collection was re-identified and a repeat needle puncture was performed, but this time there was purulent fluid as well as blood was aspirated. An ___ catheter was placed into the left chest, there was no significant drainage, and the catheter was subsequently removed. CXR afterwards shows mild infiltrate in the left lung, but overall significantly improved. A couple hours after his procedure while on the medical floor, the patient started to have hemoptysis and started to desaturate. He was intubated and transferred to the ICU at that time. The airway was without blood, a suction catheter had been passed without gross blood suctioned and he was appropriately sedated. CXR then showed a loculated dense fluid within the left chest consistent with a hemothorax. While at ___, he received 2U of pRBCs, 2U of FFP, and 2U of platelets. His antibiotics were broadened to meropenem. He was then transferred to ___ for thoracic surgery evaluation and further management. On arrival at ___, the patient started to require pressors to maintain MAPS >65. CXR was obtained and showed near complete opacification of the left hemithorax. Labs were significant for a hgb of 7.0 and hct 22.4, creatinine 1.6, elevated LFTs (ALT: 992, AST: ___), INR 2.4. At this time, there was concern for hemorrhagic shock with bleeding into the left thorax and the patient was being prepped for an operative procedure. Past Medical History: PMH: - former smoker - COPD - PVD - Aortic valve stenosis PSH: - multiple peripheral vascular stenting procedures and stenting of the mesenteric vessels. - TAVR in ___ ___. Social History: ___ Family History: Remarkable for patient's father having died of gastric cancer at ___. The patient's mother died of natural causes at ___. Physical Exam: Discharge physical exam: 24 HR Data (last updated ___ @ 438) Temp: 98.2 (Tm 98.8), BP: 146/70 (125-174/51-75), HR: 86 (70-96), RR: 20 (___), O2 sat: 97% (94-98), O2 delivery: Ra, Wt: 196.65 lb/89.2 kg Fluid Balance (last updated ___ @ 436) Last 8 hours Total cumulative -580ml IN: Total 120ml, PO Amt 120ml OUT: Total 700ml, Urine Amt 700ml Last 24 hours Total cumulative -1.3ml IN: Total 1298.7ml, PO Amt 810ml, IV Amt Infused 488.7ml OUT: Total 1300ml, Urine Amt 1300ml Gen: [x] NAD, [] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, no inc wob Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding Wound: [x] incisions clean, dry, intact - Left CT sites with some underlying firmness, no excessive drainage Ext: [x] warm, [] tender, [] edema - Rt foot with diminished sensation to sharp and dull stimuli below ankle - Rt foot with Dopplerable pulses: monophasic ___, biphasic DP below ankle Pertinent Results: ___ 04:15AM BLOOD WBC-10.8* RBC-2.88* Hgb-8.4* Hct-26.4* MCV-92 MCH-29.2 MCHC-31.8* RDW-18.0* RDWSD-59.3* Plt ___ ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-139 K-4.1 Cl-110* HCO3-22 AnGap-7* ___ 03:44AM BLOOD estGFR-Using this ___ 02:28AM BLOOD ALT-931* AST-781* CK(CPK)-4145* AlkPhos-180* TotBili-2.6* ___ 04:15AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.5* CXR ___: IMPRESSION: Comparison to ___, 7:30 a.m.. The pigtail catheter on the left was removed. No evidence of pneumothorax. Stable extent of the left pleural fluid collection. Stable appearance of the right lung. Arterial non-invasives ___ FINDINGS: RIGHT BRACHIAL PRESSURE: Not obtained due to line placement LEFT BRACHIAL PRESSURE: 151 mmHg RIGHT LOWER EXTREMITY Posterior Tibial Artery Pressure: 55 Dorsalis Pedis Artery Pressure: 47 Toe Pressure:25 Right ABI: 0.36 Right TBI: 0.17 DOPPLER WAVEFORMS Common Femoral Artery: monophasic Femoral Artery: monophasic Popliteal Artery: monophasic Posterior Tibial Artery: monophasic Dorsalis Pedis Artery: monophasic PULSED VOLUME WAVEFORMS Low thigh: severely abnormal Calf: severely abnormal Ankle: severely abnormal Metatarsal: severely abnormal Digit: severely abnormal LEFT LOWER EXTREMITY Posterior Tibial Artery Pressure: 104 Dorsalis Pedis Artery Pressure: 98 Toe Pressure: 85 Left ABI: 0.69 Left TBI: 0.56 DOPPLER WAVEFORMS Common Femoral Artery: biphasic Femoral Artery: monophasic Popliteal Artery: monophasic Posterior Tibial Artery: monophasic Dorsalis Pedis Artery: monophasic PULSE VOLUME WAVEFORMS Low thigh: severely abnormal Calf: severely abnormal Ankle: severely abnormal Metatarsal: severely abnormal Digit: severely abnormal Brief Hospital Course: Patient is a ___ year old male with history of CAD, aortic stenosis s/p TAVR maintained on ASA and Plavix, treated for CAP since the end of ___, presenting as transfer from ___ ___ with respiratory failure, hemoptysis and shock. Presentation was likely secondary to hemorrhagic shock with bleeding into the left thorax, with likely component of septic shock as well secondary to left lung empyema. On ___, he underwent a LEFT VATS EVACUATION OF HEMOTHORAX AND PARTIAL DECORTICATION; BRONCHOSCOPY WITH LAVAGE. ICU stay ___ Transferred to the floor ___ Brief summary by system: CV: Initially required pressor support in the ICU post-op which was gradually weaned as tolerated. Cardiology involved for mildly elevated troponin that ultimately plateaued. Pt has a history of PAD and had RLE mottling and concern for ischemia post-op. Vascular surgery was consulted and he was started on a therapeutic heparin drip which he was maintained on until ___ at which point he was transitioned to prophylactic SQH. For his chronic cardiovascular history he was maintained on ASA, statin and Plavix. Metoprolol 50mg q6h was given for BP control and amlodipine 10mg was started. As patient began to mobilize toward the end of his hospital stay, he endorsed right foot numbness that has a chronic component. Given his extensive vascular history, he underwent arterial non-invasive studies on ___ with Rt ABI 0.36, Lt ABI 0.69. He will have close follow-up with vascular surgery on discharge. Resp: Patient remained intubated postoperatively until POD4. 2 surgical chest tubes were placed at the time of operation ___. ___ placed additional left apical chest tube on ___ for improved drainage. Output was monitored daily. One chest tube was removed per day on ___. Post-pull CXRs demonstrated no PTX. The patient was breathing comfortably and saturating well on room air at the time of discharge. He will continue ABx for empyema per below. GI: Patient underwent evaluation by the speech/swallow team on multiple occasions, was cleared for ground solids and thin liquids, meds whole or crushed in puree at the time of discharge Renal: Patient was followed by the renal service and required intermittent hemodialysis for oliguric ___ until ___. He ultimately achieved full recovery of renal function with normalization of creatinine and no longer required dialysis. Nephrotoxic meds including home lisinopril were held. Placed on Flomax when Foley catheter was removed to aid in voiding ID: Arrived from OSH on meropenem. Over the course of his hospital stay he was followed by the infectious disease service for management of his empyema. Initial sputum cx with growth of Pseudomonas and Enterobacter and pleural fluid with Fusobacterium and Parvimonas. Cavitary pneumonia likely ___ polymicrobial infection. Given that he was a FE___, he was also ruled out for TB. He was transitioned to a regimen of cefepime and flagyl with scheduled outpatient follow-up. Treatment with IV cefepime and PO flagyl to continue on discharge with projected end date of ___. Heme: On transfer and postoperatively, patient received 5U PRBC, ___ and 1Plt. He remained hemodynamically stable. He was also transfused 1u PRBCs on ___ and ___ for low Hct with appropriate response. He was evaluated by physical and occupational therapy who recommended placement in acute rehab facility at time of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Omeprazole 20 mg PO BID 6. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. amLODIPine 10 mg PO DAILY 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. CefePIME 1 g IV Q12H Projected end date ___ 5. Heparin 5000 UNIT SC BID 6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO Q6H 8. MetroNIDAZOLE 500 mg PO/NG Q8H Projected end date ___ 9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 10. Polyethylene Glycol 17 g PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Aspirin 81 mg PO DAILY 13. Atorvastatin 80 mg PO QPM 14. Clopidogrel 75 mg PO DAILY 15. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until discussing with your PCP/cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left hemothorax and empyema Septic shock Ischemic left lower extremity ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital for lung surgery and you've overall recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol on a standing basis to avoid more opioid use. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. * Please follow up with your cardiologist on discharge as we have adjusted some of your home medications including metoprolol and also added a new medication called amlodipine and held lisinopril. Please also follow up with Dr. ___ surgeon) regarding your lower extremity vascular disease. Call Dr. ___/ Dr. ___/ Dr. ___ if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: ___
[ "A419", "J869", "R6521", "T8119XA", "J156", "J9601", "N170", "K7200", "I21A1", "J942", "J95830", "N179", "T17590A", "D62", "D684", "E872", "I472", "Z7902", "Z87891", "J449", "I739", "Z953", "Y92239", "I2510", "I10", "I701", "Z955", "R238", "E875" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: hemothorax Major Surgical or Invasive Procedure: [MASKED] Left VATS, evacuation of hemothorax and partial decortication, bronchoscopy with lavage [MASKED] Bronchoscopy [MASKED] Right PICC placement History of Present Illness: [MASKED] with PMH of smoking for [MASKED] years (quit [MASKED] years ago), COPD, peripheral vascular disease requiring multiple stents, aortic valve disease s/p TAVR procedure (on ASA and Plavix) at the [MASKED] [MASKED] in [MASKED] who presents to [MASKED] from [MASKED] for escalation of care of respiratory distress in the setting of a left-sided hemothorax following thoracentesis performed earlier today. He was having productive yellow sputum, fever, and fatigue for which he was empirically treated with azithromycin. However, he did not improve on the antibiotics and went to the ED for further evaluation. At that time, he underwent a CT scan of the chest which showed pneumonia of the LLL with some cavitation in the LUL as well as a L pleural effusion w/ compressive atelectasis of the LLL of the lung. At that time, he was admitted to the hospital, started on IV antibiotics, and [MASKED] was consulted for thoracentesis. Under ultrasound guidance, a left-sided thoracentesis was performed with removal of purulent fluid which was sent for gram stain, which demonstrated multiple gram-positive and gram-negative organisms. During the procedure, thoracic surgery was consulted and the decision was made to leave a drainage catheter in the left chest as the fluid was grossly purulent on aspiration. However, when returning to place the drainage catheter, the thoracentesis catheter had been dislodged. Under ultrasound guidance, the fluid collection was re-identified and a repeat needle puncture was performed, but this time there was purulent fluid as well as blood was aspirated. An [MASKED] catheter was placed into the left chest, there was no significant drainage, and the catheter was subsequently removed. CXR afterwards shows mild infiltrate in the left lung, but overall significantly improved. A couple hours after his procedure while on the medical floor, the patient started to have hemoptysis and started to desaturate. He was intubated and transferred to the ICU at that time. The airway was without blood, a suction catheter had been passed without gross blood suctioned and he was appropriately sedated. CXR then showed a loculated dense fluid within the left chest consistent with a hemothorax. While at [MASKED], he received 2U of pRBCs, 2U of FFP, and 2U of platelets. His antibiotics were broadened to meropenem. He was then transferred to [MASKED] for thoracic surgery evaluation and further management. On arrival at [MASKED], the patient started to require pressors to maintain MAPS >65. CXR was obtained and showed near complete opacification of the left hemithorax. Labs were significant for a hgb of 7.0 and hct 22.4, creatinine 1.6, elevated LFTs (ALT: 992, AST: [MASKED]), INR 2.4. At this time, there was concern for hemorrhagic shock with bleeding into the left thorax and the patient was being prepped for an operative procedure. Past Medical History: PMH: - former smoker - COPD - PVD - Aortic valve stenosis PSH: - multiple peripheral vascular stenting procedures and stenting of the mesenteric vessels. - TAVR in [MASKED] [MASKED]. Social History: [MASKED] Family History: Remarkable for patient's father having died of gastric cancer at [MASKED]. The patient's mother died of natural causes at [MASKED]. Physical Exam: Discharge physical exam: 24 HR Data (last updated [MASKED] @ 438) Temp: 98.2 (Tm 98.8), BP: 146/70 (125-174/51-75), HR: 86 (70-96), RR: 20 ([MASKED]), O2 sat: 97% (94-98), O2 delivery: Ra, Wt: 196.65 lb/89.2 kg Fluid Balance (last updated [MASKED] @ 436) Last 8 hours Total cumulative -580ml IN: Total 120ml, PO Amt 120ml OUT: Total 700ml, Urine Amt 700ml Last 24 hours Total cumulative -1.3ml IN: Total 1298.7ml, PO Amt 810ml, IV Amt Infused 488.7ml OUT: Total 1300ml, Urine Amt 1300ml Gen: [x] NAD, [] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, no inc wob Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding Wound: [x] incisions clean, dry, intact - Left CT sites with some underlying firmness, no excessive drainage Ext: [x] warm, [] tender, [] edema - Rt foot with diminished sensation to sharp and dull stimuli below ankle - Rt foot with Dopplerable pulses: monophasic [MASKED], biphasic DP below ankle Pertinent Results: [MASKED] 04:15AM BLOOD WBC-10.8* RBC-2.88* Hgb-8.4* Hct-26.4* MCV-92 MCH-29.2 MCHC-31.8* RDW-18.0* RDWSD-59.3* Plt [MASKED] [MASKED] 04:15AM BLOOD Plt [MASKED] [MASKED] 04:15AM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-139 K-4.1 Cl-110* HCO3-22 AnGap-7* [MASKED] 03:44AM BLOOD estGFR-Using this [MASKED] 02:28AM BLOOD ALT-931* AST-781* CK(CPK)-4145* AlkPhos-180* TotBili-2.6* [MASKED] 04:15AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.5* CXR [MASKED]: IMPRESSION: Comparison to [MASKED], 7:30 a.m.. The pigtail catheter on the left was removed. No evidence of pneumothorax. Stable extent of the left pleural fluid collection. Stable appearance of the right lung. Arterial non-invasives [MASKED] FINDINGS: RIGHT BRACHIAL PRESSURE: Not obtained due to line placement LEFT BRACHIAL PRESSURE: 151 mmHg RIGHT LOWER EXTREMITY Posterior Tibial Artery Pressure: 55 Dorsalis Pedis Artery Pressure: 47 Toe Pressure:25 Right ABI: 0.36 Right TBI: 0.17 DOPPLER WAVEFORMS Common Femoral Artery: monophasic Femoral Artery: monophasic Popliteal Artery: monophasic Posterior Tibial Artery: monophasic Dorsalis Pedis Artery: monophasic PULSED VOLUME WAVEFORMS Low thigh: severely abnormal Calf: severely abnormal Ankle: severely abnormal Metatarsal: severely abnormal Digit: severely abnormal LEFT LOWER EXTREMITY Posterior Tibial Artery Pressure: 104 Dorsalis Pedis Artery Pressure: 98 Toe Pressure: 85 Left ABI: 0.69 Left TBI: 0.56 DOPPLER WAVEFORMS Common Femoral Artery: biphasic Femoral Artery: monophasic Popliteal Artery: monophasic Posterior Tibial Artery: monophasic Dorsalis Pedis Artery: monophasic PULSE VOLUME WAVEFORMS Low thigh: severely abnormal Calf: severely abnormal Ankle: severely abnormal Metatarsal: severely abnormal Digit: severely abnormal Brief Hospital Course: Patient is a [MASKED] year old male with history of CAD, aortic stenosis s/p TAVR maintained on ASA and Plavix, treated for CAP since the end of [MASKED], presenting as transfer from [MASKED] [MASKED] with respiratory failure, hemoptysis and shock. Presentation was likely secondary to hemorrhagic shock with bleeding into the left thorax, with likely component of septic shock as well secondary to left lung empyema. On [MASKED], he underwent a LEFT VATS EVACUATION OF HEMOTHORAX AND PARTIAL DECORTICATION; BRONCHOSCOPY WITH LAVAGE. ICU stay [MASKED] Transferred to the floor [MASKED] Brief summary by system: CV: Initially required pressor support in the ICU post-op which was gradually weaned as tolerated. Cardiology involved for mildly elevated troponin that ultimately plateaued. Pt has a history of PAD and had RLE mottling and concern for ischemia post-op. Vascular surgery was consulted and he was started on a therapeutic heparin drip which he was maintained on until [MASKED] at which point he was transitioned to prophylactic SQH. For his chronic cardiovascular history he was maintained on ASA, statin and Plavix. Metoprolol 50mg q6h was given for BP control and amlodipine 10mg was started. As patient began to mobilize toward the end of his hospital stay, he endorsed right foot numbness that has a chronic component. Given his extensive vascular history, he underwent arterial non-invasive studies on [MASKED] with Rt ABI 0.36, Lt ABI 0.69. He will have close follow-up with vascular surgery on discharge. Resp: Patient remained intubated postoperatively until POD4. 2 surgical chest tubes were placed at the time of operation [MASKED]. [MASKED] placed additional left apical chest tube on [MASKED] for improved drainage. Output was monitored daily. One chest tube was removed per day on [MASKED]. Post-pull CXRs demonstrated no PTX. The patient was breathing comfortably and saturating well on room air at the time of discharge. He will continue ABx for empyema per below. GI: Patient underwent evaluation by the speech/swallow team on multiple occasions, was cleared for ground solids and thin liquids, meds whole or crushed in puree at the time of discharge Renal: Patient was followed by the renal service and required intermittent hemodialysis for oliguric [MASKED] until [MASKED]. He ultimately achieved full recovery of renal function with normalization of creatinine and no longer required dialysis. Nephrotoxic meds including home lisinopril were held. Placed on Flomax when Foley catheter was removed to aid in voiding ID: Arrived from OSH on meropenem. Over the course of his hospital stay he was followed by the infectious disease service for management of his empyema. Initial sputum cx with growth of Pseudomonas and Enterobacter and pleural fluid with Fusobacterium and Parvimonas. Cavitary pneumonia likely [MASKED] polymicrobial infection. Given that he was a FE , he was also ruled out for TB. He was transitioned to a regimen of cefepime and flagyl with scheduled outpatient follow-up. Treatment with IV cefepime and PO flagyl to continue on discharge with projected end date of [MASKED]. Heme: On transfer and postoperatively, patient received 5U PRBC, [MASKED] and 1Plt. He remained hemodynamically stable. He was also transfused 1u PRBCs on [MASKED] and [MASKED] for low Hct with appropriate response. He was evaluated by physical and occupational therapy who recommended placement in acute rehab facility at time of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Omeprazole 20 mg PO BID 6. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. amLODIPine 10 mg PO DAILY 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. CefePIME 1 g IV Q12H Projected end date [MASKED] 5. Heparin 5000 UNIT SC BID 6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO Q6H 8. MetroNIDAZOLE 500 mg PO/NG Q8H Projected end date [MASKED] 9. OxyCODONE (Immediate Release) [MASKED] mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 10. Polyethylene Glycol 17 g PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Aspirin 81 mg PO DAILY 13. Atorvastatin 80 mg PO QPM 14. Clopidogrel 75 mg PO DAILY 15. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until discussing with your PCP/cardiologist Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left hemothorax and empyema Septic shock Ischemic left lower extremity [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital for lung surgery and you've overall recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol on a standing basis to avoid more opioid use. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk [MASKED] times a day and gradually increase your activity as you can tolerate. * Please follow up with your cardiologist on discharge as we have adjusted some of your home medications including metoprolol and also added a new medication called amlodipine and held lisinopril. Please also follow up with Dr. [MASKED] surgeon) regarding your lower extremity vascular disease. Call Dr. [MASKED]/ Dr. [MASKED]/ Dr. [MASKED] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: [MASKED]
[]
[ "J9601", "N179", "D62", "E872", "Z7902", "Z87891", "J449", "I2510", "I10", "Z955" ]
[ "A419: Sepsis, unspecified organism", "J869: Pyothorax without fistula", "R6521: Severe sepsis with septic shock", "T8119XA: Other postprocedural shock, initial encounter", "J156: Pneumonia due to other Gram-negative bacteria", "J9601: Acute respiratory failure with hypoxia", "N170: Acute kidney failure with tubular necrosis", "K7200: Acute and subacute hepatic failure without coma", "I21A1: Myocardial infarction type 2", "J942: Hemothorax", "J95830: Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure", "N179: Acute kidney failure, unspecified", "T17590A: Other foreign object in bronchus causing asphyxiation, initial encounter", "D62: Acute posthemorrhagic anemia", "D684: Acquired coagulation factor deficiency", "E872: Acidosis", "I472: Ventricular tachycardia", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z87891: Personal history of nicotine dependence", "J449: Chronic obstructive pulmonary disease, unspecified", "I739: Peripheral vascular disease, unspecified", "Z953: Presence of xenogenic heart valve", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "I701: Atherosclerosis of renal artery", "Z955: Presence of coronary angioplasty implant and graft", "R238: Other skin changes", "E875: Hyperkalemia" ]
10,055,939
29,166,650
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chronic abdominal pain and severe stenosis of the origin of the celiac artery as well as the SMA. Major Surgical or Invasive Procedure: Superior Mesenteric Artery angioplasty and stent via left groin access. History of Present Illness: ___ is a ___ man with a history of chronic abdominal pain, weight loss and the finding on MRA of a very severe stenosis of the origin of the celiac artery as well as the SMA. He was therefore offered visceral angiogram with possible intervention. Of note, his MRA also revealed chronic occlusion of his right iliac artery, so access will be obtained via the left common femoral. Risks, benefits and alternatives to this course of treatment were explained to the patient in detail and he consented to proceed. Past Medical History: PAST SURGICAL HISTORY: Remarkable for back surgery and ankle surgery. Social History: ___ Family History: Remarkable for patient's father having died of gastric cancer at ___. The patient's mother died of natural causes at ___. Physical Exam: VITAL SIGNS (___): Temp 98.1 BP 102/62 HR 81 RR 17 Sat 97% GENERAL: Well appearing, well nourished, in no distress ABDOMEN: Nontender, non distended. Abdomen flat, no audible bruit in the epigastrium. There is no mass. EXTREMITIES: no evidence of cyanosis, edema or varicosities NEUROLOGIC: Intact, alert and oriented x 3. Brief Hospital Course: Mr. ___ arrived to ___ for admission on ___, same day of his planned procedure of visceral angiogram with possible intervention. Upon arrival Mr. ___ was placed NPO for his procedure and all of his home medications were ordered. Mr. ___ was placed under moderate conscious sedation. A realtime ultrasound-guided access to the left common femoral artery and placement of a ___ TourGuide sheath was performed. Normal-caliber visceral segment of the aorta, with severe stenosis at the origin of the SMA and celiac arteries was seen, consistent with recent MRA identified stenosis.Patient underwent angioplasty and stunting of the origin of the superior mesenteric artery. The patient tolerated the procedure well. Pressure was held at the left groin for 20 minutes with excellent hemostasis and signals were noted throughout in both feet bilaterally at the end of the procedure. The patient was then observed with serial examinations until the return of his pre-sedation mental status and then was taken to the PACU for further recovery. Patient was taken to the floor and monitored for abdominal pain and bleeding from his groin. Next day, on ___ the patient was advanced to regular diet and multiple abdominal exams were performed. The patient tolerated diet well and complained of no abdominal pain. The patient was stable and cleared from his vascular surgery and was discharged home to continue his recovery. Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Severe 2. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY RX *aspirin [Enteric Coated Aspirin] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Lisinopril 20 mg PO DAILY 5. Omeprazole 20 mg PO BID 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Chronic mesenteric ischemia with severe celiac and Superior Mesenteric Artery stenosis status post Superior Mesenteric Artery angioplasty and stent. 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 a Superior Mesenteric Artery angioplasty and stent placement. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATION: • Take Aspirin 81mg once daily • Take Plavix (Clopidogrel) 75mg once daily • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: • It is normal to 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 • Abdominal pain • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) • Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___
[ "K551", "I774", "I745", "I708", "Z7902", "E46", "Z6823", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chronic abdominal pain and severe stenosis of the origin of the celiac artery as well as the SMA. Major Surgical or Invasive Procedure: Superior Mesenteric Artery angioplasty and stent via left groin access. History of Present Illness: [MASKED] is a [MASKED] man with a history of chronic abdominal pain, weight loss and the finding on MRA of a very severe stenosis of the origin of the celiac artery as well as the SMA. He was therefore offered visceral angiogram with possible intervention. Of note, his MRA also revealed chronic occlusion of his right iliac artery, so access will be obtained via the left common femoral. Risks, benefits and alternatives to this course of treatment were explained to the patient in detail and he consented to proceed. Past Medical History: PAST SURGICAL HISTORY: Remarkable for back surgery and ankle surgery. Social History: [MASKED] Family History: Remarkable for patient's father having died of gastric cancer at [MASKED]. The patient's mother died of natural causes at [MASKED]. Physical Exam: VITAL SIGNS ([MASKED]): Temp 98.1 BP 102/62 HR 81 RR 17 Sat 97% GENERAL: Well appearing, well nourished, in no distress ABDOMEN: Nontender, non distended. Abdomen flat, no audible bruit in the epigastrium. There is no mass. EXTREMITIES: no evidence of cyanosis, edema or varicosities NEUROLOGIC: Intact, alert and oriented x 3. Brief Hospital Course: Mr. [MASKED] arrived to [MASKED] for admission on [MASKED], same day of his planned procedure of visceral angiogram with possible intervention. Upon arrival Mr. [MASKED] was placed NPO for his procedure and all of his home medications were ordered. Mr. [MASKED] was placed under moderate conscious sedation. A realtime ultrasound-guided access to the left common femoral artery and placement of a [MASKED] TourGuide sheath was performed. Normal-caliber visceral segment of the aorta, with severe stenosis at the origin of the SMA and celiac arteries was seen, consistent with recent MRA identified stenosis.Patient underwent angioplasty and stunting of the origin of the superior mesenteric artery. The patient tolerated the procedure well. Pressure was held at the left groin for 20 minutes with excellent hemostasis and signals were noted throughout in both feet bilaterally at the end of the procedure. The patient was then observed with serial examinations until the return of his pre-sedation mental status and then was taken to the PACU for further recovery. Patient was taken to the floor and monitored for abdominal pain and bleeding from his groin. Next day, on [MASKED] the patient was advanced to regular diet and multiple abdominal exams were performed. The patient tolerated diet well and complained of no abdominal pain. The patient was stable and cleared from his vascular surgery and was discharged home to continue his recovery. Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Severe 2. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY RX *aspirin [Enteric Coated Aspirin] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Lisinopril 20 mg PO DAILY 5. Omeprazole 20 mg PO BID 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Chronic mesenteric ischemia with severe celiac and Superior Mesenteric Artery stenosis status post Superior Mesenteric Artery angioplasty and stent. 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 a Superior Mesenteric Artery angioplasty and stent placement. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATION: • Take Aspirin 81mg once daily • Take Plavix (Clopidogrel) 75mg once daily • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: • It is normal to 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 • Abdominal pain • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) • Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [MASKED]. If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. Followup Instructions: [MASKED]
[]
[ "Z7902", "Z87891" ]
[ "K551: Chronic vascular disorders of intestine", "I774: Celiac artery compression syndrome", "I745: Embolism and thrombosis of iliac artery", "I708: Atherosclerosis of other arteries", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E46: Unspecified protein-calorie malnutrition", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "Z87891: Personal history of nicotine dependence" ]
10,056,612
20,434,122
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines / latex Attending: ___. Chief Complaint: facial droop, facial weakness Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ ___ female with a PMHx of laryngeal cancer s/p resection and radiation with R temporal lesion thought to be due to radiation necrosis (followed by Dr. ___, episodes of R facial pain, chronic daily HA, and episodes of panic, confusion, and R hemibody numbness (?szs per Dr. ___, and PNES who presents with R facial droop and R-sided weakness lasting approximately 15 minutes. By the time of evaluation, these symptoms had resolved. Her NCHCT did not reveal any evidence of stroke, and her vessels were patent on CTA H/N, revealing only her prior carotid stent as well as some basilar narrowing seen on prior imaging. The latter may be due to radion vasculopathy. Her NIHSS was 2 (could not name cactus, neglected left hemibody). Her symptoms localize to a L MCA distribution. Of note, she was recently admitted to neurology for episodes of bilateral ___ weakness, dysarthria, out of body sensation, vertigo, and headache; she was evaluated by EEG, and her episodes did not have an EEG correlate and were thought to be due to panic attacks. Given that headache occurred after symptoms, migraine with aura less likely. Seizure less likely given prolonged event and recent work-up. Panic attcks as well as PNES, however, are diagnoses of exclusion and she will need a TIA work-up. Of note she had a recent admission to the neurology services where she had long term EEG eval which showed no seizure activity and likely panic attacks. She was discahgred with neurology and psychiatry followup. Of note primary concern at moment is TIA r/o before assuming above episodes is PNES. She is being admitted to medicine service for concern of hypokalemia (3.1) and hyponatremia (132), likely due to viral gastroenteritis. Her CT abd/pelvis in ED was wnl, and lactate wnl. In the ED, initial vital signs were: 97.7 66 131/78 16 97% RA - Labs were notable for: negative u/a, negative blood culture, wnl cbc, Cr 1.2 from 1.0, Na 132 from 141. - Imaging: CT Abd pelvis: . No acute findings in the abdomen or pelvis. 2. Small volume free pelvic fluid of unclear etiology, unchanged since the prior exam. - The patient was given: 1 L NS, - Consults: Neurology - felt needs workup for TIA, medicine admit given ___ Cr 1.2 from 1.0. Vitals prior to transfer were: 98.1 61 155/59 16 98% RA Upon arrival to the floor, I spoke with patient and her daughter. Daughter reports that after eating soup with cheese yesterday patient had significant nausea and vomiting. No fevers or chills. No dysuria. No SOB. Mild headaches. She reports that it was tonight for her to keep anything down since ingesting soup yesterday. Daughter reports at at around 10 last night for about ___ minutes, patient become acutely somnolent and then couldn't remember where they were (en route to hospital), and that she had a right facial droop and right arm numbness. She reports she was bringing her mom in given concern for elevated blood pressure the past day (sys up to 190's). Past Medical History: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER ___, FOLLOWED AT ___ THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___ BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT ___ ? SEASONAL AFFECTIVE D/O ___: Admitted to ___ for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. ___ admission for PNES Social History: ___ Family History: - Strong family history of malignancy. One brother deceased in his ___ with liver malignancy, another in his ___ with Lung Cancer. Mother deceased (reportedly at ___) in the setting of multiple medical problems plus a stroke. Her father died at ___. - Patient denies other neurologic family history other than the above. Physical Exam: ON ADMISSION VITALS: T 98 HR 60 BP 150/61 RR 19 98 % RA GENERAL: Pleasant, well-appearing, occasionally dry heaving HEENT - normocephalic, atraumatic NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally over anterior and axillary chest ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: CNII-XII grossly intact, moves all extremeities sponatenously. ___ str plantarflex/dorsiflex, can squeeze fingers B/L ON DISCHARGE VITALS: T 97.9 BP 158/85 HR 86 RR 18 SPO2 99% on RA GENERAL: Pleasant, well-appearing HEENT - normocephalic, atraumatic NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally over anterior and axillary chest ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: CNII-XII grossly intact, moves all extremities spontaneously. Gait slowed but normal. Pertinent Results: ADMISSION LABS ========================== ___ 11:20PM BLOOD WBC-5.8 RBC-5.09 Hgb-14.1 Hct-41.5 MCV-82 MCH-27.7 MCHC-34.0 RDW-15.3 RDWSD-45.2 Plt ___ ___ 11:20PM BLOOD Glucose-89 UreaN-37* Creat-1.2* Na-132* K-3.1* Cl-94* HCO3-23 AnGap-18 ___ 11:20PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.0 Mg-2.2 Cholest-225* ___ 09:13AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 ___ 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:34PM BLOOD Lactate-1.6 MICROBIOLOGY =========================== **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 11:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING & STUDIES =========================== ___ CTA HEAD/NECK WWO CONTRAST IMPRESSION: 1. Extensive confluent white matter disease, likely secondary to combination of posttreatment changes and chronic microvascular ischemic disease, which limits evaluation for acute infarct. 2. Geographic hypodensity in the right subcortical temporal lobe is consistent with previously seen vasogenic edema. Recommend correlation with prior MRI from ___. 3. No evidence for acute intracranial hemorrhage. 4. Patent right common carotid/internal carotid artery stent. 5. Stable short segment focal high-grade stenosis of the mid-basilar artery. 6. Stable right upper lobe lung nodules since ___. CXR PA/Lat ___ IMPRESSION: No acute cardiopulmonary abnormality. EEG ___ IMPRESSION: This is an abnormal routine EEG in the awake and drowsy states due to the presence of frequent bursts of generalized delta frequency slowing as well as occasional bursts of right frontotemporal focal delta frequency slowing during wakefulness. These findings are consistent with deep midline brain dysfunction and an additional independent focus of subcortical dysfunction in the right frontotemporal region. The background is mildly disorganized, suggesting a mild diffuse encephalopathy. There are no epileptiform discharges or electrographic seizures in this recording. CT ABD/PELV WO CONTRAST ___ IMPRESSION: 1. No acute findings in the abdomen or pelvis. 2. Small volume free pelvic fluid of unclear etiology, unchanged since the prior exam. 3. Fibroid uterus. TTE ___ Conclusions The left atrial volume index is normal. 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%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic stenosis is pesent. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild mitral leaflet and subvalvular apparatus thickening with mild-moderate mitral regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Increased PCWP. No definite structural cardiac source of embolism identified. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. MR HEAD WO CONTRAST ___ IMPRESSION: 1. Small acute infarctions in the pons and posterior superior right cerebellar hemisphere. No evidence of hemorrhage, edema or mass effect. 2. Extensive stable matter signal abnormality, likely combination of posttreatment changes and chronic microvascular ischemic disease. 3. Stable subcortical white matter disease in the right temporal lobe. Previously seen contrast enhancing lesion in the right temporal lobe is similar in size to prior examination measuring approximately 1.1 cm in greatest dimension, however incompletely characterized given lack of contrast administration on the current examination. DISCHARGE LABS ========================= ___ 05:56AM BLOOD WBC-4.1 RBC-4.55 Hgb-12.4 Hct-38.2 MCV-84 MCH-27.3 MCHC-32.5 RDW-15.9* RDWSD-48.6* Plt ___ ___ 05:56AM BLOOD Calcium-8.6 Phos-3.9# Mg-1.9 ___ 05:56AM BLOOD Glucose-83 UreaN-17 Creat-0.9 Na-140 K-3.0* Cl-102 HCO3-26 AnGap-___ ___ female with a PMHx of laryngeal cancer s/p resection and radiation with R temporal lesion thought to be due to radiation necrosis (followed by Dr. ___, episodes of R facial pain, chronic daily HA, and episodes of panic, confusion, and R hemibody numbness (?szs per Dr. ___, and PNES, who came into ED with nausea/vomiting and right sided numbness. Largely negative workup except for orthostatic hypotension. Then found to have small cerebellar and pontine infarcts on MRI. # Cerebellar/pontine stroke: Per MRI, very small infarcts in this region. Likely due to decreased perfusion in the setting of gastroenteritis and very narrow basilar artery. She did not appear to have consequential gross neurologic deficits during this admission. Her 20min EEG was not concerning. Her transient facial droop and numbness does not correspond to the location of the lesion and reportedly occurred in the past, though to be possibly related to her PNES per Dr. ___. She does have hyperlipidemia with LDL 163, so clopidogrel and atorvastatin 80mg daily were started for secondary prevention. Start dual antiplatelet therapy, add clopidogrel to current aspirin therapy. She will follow up with her current neurologist Dr. ___ have home ___. # Viral gastroenteritis/orthostatic hypotension: Pt reported nausea/vomiting prior to admission and had positive orthostatic vital signs in the ED. She also has had poor PO intake chronically. Her GI symptoms improved during the admission. She was started on nutrition supplements and given IV fluids, with good response. She worked with ___ on day of discharge without symptoms. Her antihypertensives were held at discharge. SBPs were 150s at discharge. She was encouraged to take PO and nutritional supplements. # Hypothyroidism: TSH was 34 at admission. Given her altered mental status and orthostatic hypotension, her home levothyroxine was increased from 50mcg to 75mcg daily. CHRONIC ISSUES ================================== # Hypertension: Her home antihypertensives were held in the setting of orthostatic hypotension. # PNES: Topamax and lorazepam were initially held given her altered mental status. Topamax was restarted but lorazepam was held to prevent further episodes of confusion after discussion with family and outpatient neurologist. # Depression: She was continued on sertraline. TRANSITIONAL ISSUES ================================== -Patient should work with home ___ given deconditioning from her acute illness and acute stroke -Please recheck TSH in ___ weeks and adjust levothyroxine dose as necessary. -Home lorazepam was held given her altered mental status, and after discussion with outpatient neurologist Dr. ___ -___ orthostatic hypotension, antihypertensives were held at discharge. Her supine SBPs were 150s at discharge. Please check orthostatic vital signs at home and PCP followup and consider restarting if hypertensive. -Per family, patient has had gradual decline in cognitive function and hearing. Please discuss at PCP appointment whether hearing aids would be appropriate. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO BID 8. LORazepam 0.5 mg PO BID 9. Sertraline 25 mg PO DAILY 10. Loratadine 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fish Oil (Omega 3) 1000 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Sertraline 25 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO BID 6. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Loratadine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Acute cerebellar and pontine CVA Viral Gastroenteritis Presyncopal event due to hypovolemia SECONDARY: Orthostatic hypotension Hypothyroidism PNES 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 Ms. ___, You came to the hospital because you had nausea, vomiting and felt numb on your right side. At the hospital you were evaluated by our medicine doctors and our ___. Our neurologists determined that you had a very small stroke in your cerebellum and pons, and our medicine doctors determined ___ might have fainted because of volume loss from a stomach bug. We are discharging you home with physical therapy services so you can get stronger. We ask that you follow up with your neurologist and primary care doctor as below. We wish you all the best! -Your ___ Care Team Followup Instructions: ___
[ "I638", "E871", "G4089", "E861", "R55", "A084", "E890", "E876", "E785", "R29810", "I10", "F329", "I6789", "Y842", "G4489", "R200", "F419", "Z8521", "Z87891", "Z923", "Z66" ]
Allergies: Influenza Virus Vaccines / latex Chief Complaint: facial droop, facial weakness Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] [MASKED] female with a PMHx of laryngeal cancer s/p resection and radiation with R temporal lesion thought to be due to radiation necrosis (followed by Dr. [MASKED], episodes of R facial pain, chronic daily HA, and episodes of panic, confusion, and R hemibody numbness (?szs per Dr. [MASKED], and PNES who presents with R facial droop and R-sided weakness lasting approximately 15 minutes. By the time of evaluation, these symptoms had resolved. Her NCHCT did not reveal any evidence of stroke, and her vessels were patent on CTA H/N, revealing only her prior carotid stent as well as some basilar narrowing seen on prior imaging. The latter may be due to radion vasculopathy. Her NIHSS was 2 (could not name cactus, neglected left hemibody). Her symptoms localize to a L MCA distribution. Of note, she was recently admitted to neurology for episodes of bilateral [MASKED] weakness, dysarthria, out of body sensation, vertigo, and headache; she was evaluated by EEG, and her episodes did not have an EEG correlate and were thought to be due to panic attacks. Given that headache occurred after symptoms, migraine with aura less likely. Seizure less likely given prolonged event and recent work-up. Panic attcks as well as PNES, however, are diagnoses of exclusion and she will need a TIA work-up. Of note she had a recent admission to the neurology services where she had long term EEG eval which showed no seizure activity and likely panic attacks. She was discahgred with neurology and psychiatry followup. Of note primary concern at moment is TIA r/o before assuming above episodes is PNES. She is being admitted to medicine service for concern of hypokalemia (3.1) and hyponatremia (132), likely due to viral gastroenteritis. Her CT abd/pelvis in ED was wnl, and lactate wnl. In the ED, initial vital signs were: 97.7 66 131/78 16 97% RA - Labs were notable for: negative u/a, negative blood culture, wnl cbc, Cr 1.2 from 1.0, Na 132 from 141. - Imaging: CT Abd pelvis: . No acute findings in the abdomen or pelvis. 2. Small volume free pelvic fluid of unclear etiology, unchanged since the prior exam. - The patient was given: 1 L NS, - Consults: Neurology - felt needs workup for TIA, medicine admit given [MASKED] Cr 1.2 from 1.0. Vitals prior to transfer were: 98.1 61 155/59 16 98% RA Upon arrival to the floor, I spoke with patient and her daughter. Daughter reports that after eating soup with cheese yesterday patient had significant nausea and vomiting. No fevers or chills. No dysuria. No SOB. Mild headaches. She reports that it was tonight for her to keep anything down since ingesting soup yesterday. Daughter reports at at around 10 last night for about [MASKED] minutes, patient become acutely somnolent and then couldn't remember where they were (en route to hospital), and that she had a right facial droop and right arm numbness. She reports she was bringing her mom in given concern for elevated blood pressure the past day (sys up to 190's). Past Medical History: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy [MASKED] years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER [MASKED], FOLLOWED AT [MASKED] THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, [MASKED] BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT [MASKED] ? SEASONAL AFFECTIVE D/O [MASKED]: Admitted to [MASKED] for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. [MASKED] admission for PNES Social History: [MASKED] Family History: - Strong family history of malignancy. One brother deceased in his [MASKED] with liver malignancy, another in his [MASKED] with Lung Cancer. Mother deceased (reportedly at [MASKED]) in the setting of multiple medical problems plus a stroke. Her father died at [MASKED]. - Patient denies other neurologic family history other than the above. Physical Exam: ON ADMISSION VITALS: T 98 HR 60 BP 150/61 RR 19 98 % RA GENERAL: Pleasant, well-appearing, occasionally dry heaving HEENT - normocephalic, atraumatic NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally over anterior and axillary chest ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: CNII-XII grossly intact, moves all extremeities sponatenously. [MASKED] str plantarflex/dorsiflex, can squeeze fingers B/L ON DISCHARGE VITALS: T 97.9 BP 158/85 HR 86 RR 18 SPO2 99% on RA GENERAL: Pleasant, well-appearing HEENT - normocephalic, atraumatic NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally over anterior and axillary chest ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: CNII-XII grossly intact, moves all extremities spontaneously. Gait slowed but normal. Pertinent Results: ADMISSION LABS ========================== [MASKED] 11:20PM BLOOD WBC-5.8 RBC-5.09 Hgb-14.1 Hct-41.5 MCV-82 MCH-27.7 MCHC-34.0 RDW-15.3 RDWSD-45.2 Plt [MASKED] [MASKED] 11:20PM BLOOD Glucose-89 UreaN-37* Creat-1.2* Na-132* K-3.1* Cl-94* HCO3-23 AnGap-18 [MASKED] 11:20PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.0 Mg-2.2 Cholest-225* [MASKED] 09:13AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 [MASKED] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 11:34PM BLOOD Lactate-1.6 MICROBIOLOGY =========================== **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 11:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING & STUDIES =========================== [MASKED] CTA HEAD/NECK WWO CONTRAST IMPRESSION: 1. Extensive confluent white matter disease, likely secondary to combination of posttreatment changes and chronic microvascular ischemic disease, which limits evaluation for acute infarct. 2. Geographic hypodensity in the right subcortical temporal lobe is consistent with previously seen vasogenic edema. Recommend correlation with prior MRI from [MASKED]. 3. No evidence for acute intracranial hemorrhage. 4. Patent right common carotid/internal carotid artery stent. 5. Stable short segment focal high-grade stenosis of the mid-basilar artery. 6. Stable right upper lobe lung nodules since [MASKED]. CXR PA/Lat [MASKED] IMPRESSION: No acute cardiopulmonary abnormality. EEG [MASKED] IMPRESSION: This is an abnormal routine EEG in the awake and drowsy states due to the presence of frequent bursts of generalized delta frequency slowing as well as occasional bursts of right frontotemporal focal delta frequency slowing during wakefulness. These findings are consistent with deep midline brain dysfunction and an additional independent focus of subcortical dysfunction in the right frontotemporal region. The background is mildly disorganized, suggesting a mild diffuse encephalopathy. There are no epileptiform discharges or electrographic seizures in this recording. CT ABD/PELV WO CONTRAST [MASKED] IMPRESSION: 1. No acute findings in the abdomen or pelvis. 2. Small volume free pelvic fluid of unclear etiology, unchanged since the prior exam. 3. Fibroid uterus. TTE [MASKED] Conclusions The left atrial volume index is normal. 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%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic stenosis is pesent. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([MASKED]) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild mitral leaflet and subvalvular apparatus thickening with mild-moderate mitral regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Increased PCWP. No definite structural cardiac source of embolism identified. CLINICAL IMPLICATIONS: Based on [MASKED] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. MR HEAD WO CONTRAST [MASKED] IMPRESSION: 1. Small acute infarctions in the pons and posterior superior right cerebellar hemisphere. No evidence of hemorrhage, edema or mass effect. 2. Extensive stable matter signal abnormality, likely combination of posttreatment changes and chronic microvascular ischemic disease. 3. Stable subcortical white matter disease in the right temporal lobe. Previously seen contrast enhancing lesion in the right temporal lobe is similar in size to prior examination measuring approximately 1.1 cm in greatest dimension, however incompletely characterized given lack of contrast administration on the current examination. DISCHARGE LABS ========================= [MASKED] 05:56AM BLOOD WBC-4.1 RBC-4.55 Hgb-12.4 Hct-38.2 MCV-84 MCH-27.3 MCHC-32.5 RDW-15.9* RDWSD-48.6* Plt [MASKED] [MASKED] 05:56AM BLOOD Calcium-8.6 Phos-3.9# Mg-1.9 [MASKED] 05:56AM BLOOD Glucose-83 UreaN-17 Creat-0.9 Na-140 K-3.0* Cl-102 HCO3-26 AnGap-[MASKED] [MASKED] female with a PMHx of laryngeal cancer s/p resection and radiation with R temporal lesion thought to be due to radiation necrosis (followed by Dr. [MASKED], episodes of R facial pain, chronic daily HA, and episodes of panic, confusion, and R hemibody numbness (?szs per Dr. [MASKED], and PNES, who came into ED with nausea/vomiting and right sided numbness. Largely negative workup except for orthostatic hypotension. Then found to have small cerebellar and pontine infarcts on MRI. # Cerebellar/pontine stroke: Per MRI, very small infarcts in this region. Likely due to decreased perfusion in the setting of gastroenteritis and very narrow basilar artery. She did not appear to have consequential gross neurologic deficits during this admission. Her 20min EEG was not concerning. Her transient facial droop and numbness does not correspond to the location of the lesion and reportedly occurred in the past, though to be possibly related to her PNES per Dr. [MASKED]. She does have hyperlipidemia with LDL 163, so clopidogrel and atorvastatin 80mg daily were started for secondary prevention. Start dual antiplatelet therapy, add clopidogrel to current aspirin therapy. She will follow up with her current neurologist Dr. [MASKED] have home [MASKED]. # Viral gastroenteritis/orthostatic hypotension: Pt reported nausea/vomiting prior to admission and had positive orthostatic vital signs in the ED. She also has had poor PO intake chronically. Her GI symptoms improved during the admission. She was started on nutrition supplements and given IV fluids, with good response. She worked with [MASKED] on day of discharge without symptoms. Her antihypertensives were held at discharge. SBPs were 150s at discharge. She was encouraged to take PO and nutritional supplements. # Hypothyroidism: TSH was 34 at admission. Given her altered mental status and orthostatic hypotension, her home levothyroxine was increased from 50mcg to 75mcg daily. CHRONIC ISSUES ================================== # Hypertension: Her home antihypertensives were held in the setting of orthostatic hypotension. # PNES: Topamax and lorazepam were initially held given her altered mental status. Topamax was restarted but lorazepam was held to prevent further episodes of confusion after discussion with family and outpatient neurologist. # Depression: She was continued on sertraline. TRANSITIONAL ISSUES ================================== -Patient should work with home [MASKED] given deconditioning from her acute illness and acute stroke -Please recheck TSH in [MASKED] weeks and adjust levothyroxine dose as necessary. -Home lorazepam was held given her altered mental status, and after discussion with outpatient neurologist Dr. [MASKED] -[MASKED] orthostatic hypotension, antihypertensives were held at discharge. Her supine SBPs were 150s at discharge. Please check orthostatic vital signs at home and PCP followup and consider restarting if hypertensive. -Per family, patient has had gradual decline in cognitive function and hearing. Please discuss at PCP appointment whether hearing aids would be appropriate. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO BID 8. LORazepam 0.5 mg PO BID 9. Sertraline 25 mg PO DAILY 10. Loratadine 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fish Oil (Omega 3) 1000 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Sertraline 25 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO BID 6. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Loratadine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: Acute cerebellar and pontine CVA Viral Gastroenteritis Presyncopal event due to hypovolemia SECONDARY: Orthostatic hypotension Hypothyroidism PNES 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 Ms. [MASKED], You came to the hospital because you had nausea, vomiting and felt numb on your right side. At the hospital you were evaluated by our medicine doctors and our [MASKED]. Our neurologists determined that you had a very small stroke in your cerebellum and pons, and our medicine doctors determined [MASKED] might have fainted because of volume loss from a stomach bug. We are discharging you home with physical therapy services so you can get stronger. We ask that you follow up with your neurologist and primary care doctor as below. We wish you all the best! -Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E871", "E785", "I10", "F329", "F419", "Z87891", "Z66" ]
[ "I638: Other cerebral infarction", "E871: Hypo-osmolality and hyponatremia", "G4089: Other seizures", "E861: Hypovolemia", "R55: Syncope and collapse", "A084: Viral intestinal infection, unspecified", "E890: Postprocedural hypothyroidism", "E876: Hypokalemia", "E785: Hyperlipidemia, unspecified", "R29810: Facial weakness", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "I6789: Other cerebrovascular disease", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "G4489: Other headache syndrome", "R200: Anesthesia of skin", "F419: Anxiety disorder, unspecified", "Z8521: Personal history of malignant neoplasm of larynx", "Z87891: Personal history of nicotine dependence", "Z923: Personal history of irradiation", "Z66: Do not resuscitate" ]
10,056,612
20,943,307
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / lisinopril / chlorthalidone Attending: ___ Chief Complaint: Headache and dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with history of laryngeal cancer and L temporal lesion as well as history of multiple lacunar infarcts and microvascular disease as well as recent admission for hypertensive emergency and headache during which she was found to have small L cerebellar infarct who presents to the ED with headache and dizziness. Ms. ___ was recently admitted from ___ through ___ to the medicine service after presenting with hypertensive emergency. Course complicated by status migrainosus, which resolved after 3 days of IV dexamethasone and for which she was started on acetazolamide. Course also complicated by incidental tiny left cerebellar infarct thought by medicine team to be likely related to hypertension. This was treated as an aspirin failure and she was switched to Plavix. She is not on a statin due to reported statin allergy. During admission she was evaluated by her outpatient neuro-oncologist, Dr. ___. At that time neurologic exam is documented as normal except brisk but symmetric reflexes, as well as moderate ataxia and aphasia with ambulation. Ms. ___ reports that her headache had resolved after discharge, but returned this afternoon. The headache started at the vertex at approx 1700, and became severe by 1800, and also spread to the R hemicranium. The headache is sharp in character. Associated with photophobia and nausea, no phonophobia, no emesis. She states that she has had headaches like this in the past, though they all started after age ___. She also describes 'dizziness' that started around the same time as the headache. She has great difficulty describing the dizziness, but states it was episodic, lasting seconds at a time, and is best described as vertigo when given choices. She says that the last time she had the vertigo was "when I was upstairs in a bed like this one". She is unable to provide an answer when asked if there are any provoking factors. She also reports chest pain, and states she did not tell the emergency room doctors because she did not want to stay overnight. Unable to complete ROS due to mental status. Past Medical History: Right submandibular cystic carcinoma diagnosed in ___, treated with modified radical neck dissection and radiation Hypertension Hypothyroidism Anemia Right ICA stenosis status post right carotid stenting Cervical cancer status post hysterectomy Tonsillectomy Appendectomy Dyslipidemia Pontine lacune Bilateral cataracts Social History: ___ Family History: She had two brothers, one died in his ___ with liver cancer and one died in his ___ with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION PHYSICAL EXAM: General: Sleepy, lying in bed covered up in multiple blankets. Intermittently appears to be in pain, stated secondary to chest discomfort. HEENT: no scleral icterus, dry MM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: Skin warm, well-perfused. Tenderness to palpation at right costochondral junction. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Sleepy, keeps eyes closed during most of the examination, opening only when necessary. Requires repeated stimulation to participate in exam. Oriented to 'hospital' but not which. States date is ___, though I needed to ask her the year, month, and date multiple times each because she kept replying ___. Difficulty providing history; provides few details, answers to direct questions are at times tangential or absent, states she is still working even though prior records indicate that she has retired. Attention severely impaired, unable to name days of week forward nor repeat a forward digit span of 4. Anomia to low frequency words though interpretation is limited by the fact that ___ is her second language. Repetition intact. Comprehension intact to simple but not complex commands. Perseverative. -Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline. - Motor: Normal bulk, increased tone bilateral lower extremities. Keeps arms outstretched for pronator drift testing only momentarily, during which bilateral pronation without downward drift is noted, before putting her arms down despite coaching. Patient has significant difficulty participating in the confrontational motor testing, but gives at least some resistance in all muscle groups, and the resistance reaches full strength for the first 3 muscle groups tested (Delt Bic Tri), and then patient has progressive difficulty cooperating with exam and symmetric 4 range effort is noted throughout the remainder of the exam. -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Abductors L 2 2 2 2 2 + + R 2 2 2 2 2 + + Plantar response was obscured by marked withdrawal bilaterally. -Sensory: Intact to LT, temperature throughout. Unable to participate in vibration or proprioceptive testing - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Patient refuses. DISCHARGE PHYSICAL EXAM: Neurologic: - Mental Status: alert and oriented x3, attention: states DOWB without difficulty, memory: ___ recall ___ with MCQ/cue), speech: normal rate, rhythm, volume, comprehension and naming intact. Able to follow complex commands - Cranial Nerves: I: not tested II: left lower quadrantopia on visual field examination III, IV, VI: EOMI without nystagmus, PERRL, no ptosis V: sensation intact to light touch VII: no facial musculature asymmetry VIII: hearing diminished but equal bilaterally IX, X: palate elevates symmetrically XI: ___ strength in trapezii and SCM bilaterally - Motor: Normal bulk and tone. No pronator drift. [___] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response showed withdrawal b/l -Sensory: Intact to LT throughout. - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Deferred. Pertinent Results: ___ 05:45AM BLOOD WBC-4.5 RBC-4.17 Hgb-11.5 Hct-34.8 MCV-84 MCH-27.6 MCHC-33.0 RDW-15.1 RDWSD-45.8 Plt ___ ___ 08:40PM BLOOD WBC-5.8 RBC-4.56 Hgb-12.7 Hct-40.2 MCV-88 MCH-27.9 MCHC-31.6* RDW-15.4 RDWSD-49.3* Plt ___ ___ 06:10AM BLOOD ___ PTT-29.2 ___ ___ 05:45AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-138 K-3.6 Cl-105 HCO3-20* AnGap-17 ___ 08:40PM BLOOD Glucose-108* UreaN-36* Creat-1.2* Na-138 K-3.7 Cl-105 HCO3-16* AnGap-21* ___ 08:40PM BLOOD ALT-18 AST-16 AlkPhos-120* TotBili-0.3 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 05:45AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 ___ 08:40PM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.4 Mg-2.3 ___ 10:02AM BLOOD %HbA1c-5.4 eAG-108 ___ 10:02AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.3 LDLcalc-150* ___ 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ CTA H&N Notable finding - Atherosclerotic vascular calcifications resulting in mild-to-moderate luminal narrowing of the petrous segment of the right ICA, similar to the prior study. Moderate luminal narrowing of the proximal to mid basilar artery again seen, likely atherosclerotic. ___ MRI head w/o contrast - Acute to subacute infarction is seen involving the right parieto-occipital lobe, left parietal lobe, and right cerebellum. Possible punctate focus of infarction is seen within the left cerebellum. Distribution appears to be embolic in etiology. - Stable extensive confluent white matter changes, right greater than left temporal white matter, bilateral frontoparietal white matter as well as middle cerebellar peduncles likely combination of posttreatment changes and sequelae of chronic small vessel ischemic disease. Brief Hospital Course: Ms. ___ is a ___ year old woman with PMH hypertension, carotid stenosis s/p R ICA stent, multiple prior strokes, CAD c/b MI, laryngeal cancer s/p surgery and radiation therapy who was admitted to Neurology stroke service with headache and dizziness. She was evaluated on telemetry and started on aspirin therapy. She was seen to have elevated LDL and due to previous statin intolerance was started on Zetia. She was seen on MRI to have ischemic stroke in the right parieto-occiptal lobe, left parietal lobe and left cerebellar lobe as well as moderate narrowing of basilar artery. These findings were suggestive of thrombotic etiology of her stroke. She underwent echocardiogram without concern. She was started on dual anti-platelet therapy with aspirin and Plavix. Her deficits (left visual field impairment, dysmetria) improved prior to discharge. She was discharged home with outpatient ___ and ___ services. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for secondary stroke prevention -pt will need to continue taking Zetia for hyperlipidemia -Will f/u pt's Echocardiogram final results; if anything concerning that is pertinent to patient's recent stroke, will contact pt to inform -Pt will need to f/u with PCP and ___ ___ on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation aerosol inhaler. ___ puffs(s) inhaled every four (4) hours as needed for cough/wheeze/chest congestion/short of breath mdi with dose counter CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth twice daily - ___ DC med rec) LEVOTHYROXINE - levothyroxine 100 mcg tablet. 1 tablet(s) by mouth once a day - ___ DC med rec) LOSARTAN - losartan 50 mg tablet. 1 tablet(s) by mouth daily - ___ DC med rec) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth qday SERTRALINE - sertraline 25 mg tablet. 1 tablet(s) by mouth - (Prescribed by Other Provider: per pt in ___ Therapist f/u So End, w/plan for ___ MD) (Not Taking as Prescribed: last filled in ___) TOPIRAMATE - topiramate 50 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider: ___. ___ TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical cream. apply to rash, hands three times a day Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth daily - ___ admission med rec) Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 2. Ezetimibe 10 mg PO DAILY RX *ezetimibe 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 4. Carvedilol 12.5 mg PO BID 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Dao;u Disp #*30 Tablet Refills:*2 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of headache and dizziness 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 cholesterol We are changing your medications as follows: - Aspirin 81 mg daily (for stroke prevention) - Clopidegrel (Plavix) 75mg daily (for stroke prevention) - Ezetimibe (Zetia) 10mg daily (for cholesterol) 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: ___
[ "I6302", "G9340", "N179", "I6782", "I10", "R278", "R51", "I2510", "I69320", "I69398", "I69393", "H5340", "I252", "E039", "E785", "Z8541", "Z8521", "Z87891", "Y842", "Z9114", "Y92009" ]
Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / lisinopril / chlorthalidone Chief Complaint: Headache and dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with history of laryngeal cancer and L temporal lesion as well as history of multiple lacunar infarcts and microvascular disease as well as recent admission for hypertensive emergency and headache during which she was found to have small L cerebellar infarct who presents to the ED with headache and dizziness. Ms. [MASKED] was recently admitted from [MASKED] through [MASKED] to the medicine service after presenting with hypertensive emergency. Course complicated by status migrainosus, which resolved after 3 days of IV dexamethasone and for which she was started on acetazolamide. Course also complicated by incidental tiny left cerebellar infarct thought by medicine team to be likely related to hypertension. This was treated as an aspirin failure and she was switched to Plavix. She is not on a statin due to reported statin allergy. During admission she was evaluated by her outpatient neuro-oncologist, Dr. [MASKED]. At that time neurologic exam is documented as normal except brisk but symmetric reflexes, as well as moderate ataxia and aphasia with ambulation. Ms. [MASKED] reports that her headache had resolved after discharge, but returned this afternoon. The headache started at the vertex at approx 1700, and became severe by 1800, and also spread to the R hemicranium. The headache is sharp in character. Associated with photophobia and nausea, no phonophobia, no emesis. She states that she has had headaches like this in the past, though they all started after age [MASKED]. She also describes 'dizziness' that started around the same time as the headache. She has great difficulty describing the dizziness, but states it was episodic, lasting seconds at a time, and is best described as vertigo when given choices. She says that the last time she had the vertigo was "when I was upstairs in a bed like this one". She is unable to provide an answer when asked if there are any provoking factors. She also reports chest pain, and states she did not tell the emergency room doctors because she did not want to stay overnight. Unable to complete ROS due to mental status. Past Medical History: Right submandibular cystic carcinoma diagnosed in [MASKED], treated with modified radical neck dissection and radiation Hypertension Hypothyroidism Anemia Right ICA stenosis status post right carotid stenting Cervical cancer status post hysterectomy Tonsillectomy Appendectomy Dyslipidemia Pontine lacune Bilateral cataracts Social History: [MASKED] Family History: She had two brothers, one died in his [MASKED] with liver cancer and one died in his [MASKED] with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION PHYSICAL EXAM: General: Sleepy, lying in bed covered up in multiple blankets. Intermittently appears to be in pain, stated secondary to chest discomfort. HEENT: no scleral icterus, dry MM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: Skin warm, well-perfused. Tenderness to palpation at right costochondral junction. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Sleepy, keeps eyes closed during most of the examination, opening only when necessary. Requires repeated stimulation to participate in exam. Oriented to 'hospital' but not which. States date is [MASKED], though I needed to ask her the year, month, and date multiple times each because she kept replying [MASKED]. Difficulty providing history; provides few details, answers to direct questions are at times tangential or absent, states she is still working even though prior records indicate that she has retired. Attention severely impaired, unable to name days of week forward nor repeat a forward digit span of 4. Anomia to low frequency words though interpretation is limited by the fact that [MASKED] is her second language. Repetition intact. Comprehension intact to simple but not complex commands. Perseverative. -Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to conversation. Palate elevates symmetrically. [MASKED] strength in trapezii bilaterally. Tongue protrudes in midline. - Motor: Normal bulk, increased tone bilateral lower extremities. Keeps arms outstretched for pronator drift testing only momentarily, during which bilateral pronation without downward drift is noted, before putting her arms down despite coaching. Patient has significant difficulty participating in the confrontational motor testing, but gives at least some resistance in all muscle groups, and the resistance reaches full strength for the first 3 muscle groups tested (Delt Bic Tri), and then patient has progressive difficulty cooperating with exam and symmetric 4 range effort is noted throughout the remainder of the exam. -DTRs: Bi Tri [MASKED] Pat Ach Pec jerk Crossed Abductors L 2 2 2 2 2 + + R 2 2 2 2 2 + + Plantar response was obscured by marked withdrawal bilaterally. -Sensory: Intact to LT, temperature throughout. Unable to participate in vibration or proprioceptive testing - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Patient refuses. DISCHARGE PHYSICAL EXAM: Neurologic: - Mental Status: alert and oriented x3, attention: states DOWB without difficulty, memory: [MASKED] recall [MASKED] with MCQ/cue), speech: normal rate, rhythm, volume, comprehension and naming intact. Able to follow complex commands - Cranial Nerves: I: not tested II: left lower quadrantopia on visual field examination III, IV, VI: EOMI without nystagmus, PERRL, no ptosis V: sensation intact to light touch VII: no facial musculature asymmetry VIII: hearing diminished but equal bilaterally IX, X: palate elevates symmetrically XI: [MASKED] strength in trapezii and SCM bilaterally - Motor: Normal bulk and tone. No pronator drift. [[MASKED]] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response showed withdrawal b/l -Sensory: Intact to LT throughout. - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Deferred. Pertinent Results: [MASKED] 05:45AM BLOOD WBC-4.5 RBC-4.17 Hgb-11.5 Hct-34.8 MCV-84 MCH-27.6 MCHC-33.0 RDW-15.1 RDWSD-45.8 Plt [MASKED] [MASKED] 08:40PM BLOOD WBC-5.8 RBC-4.56 Hgb-12.7 Hct-40.2 MCV-88 MCH-27.9 MCHC-31.6* RDW-15.4 RDWSD-49.3* Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-29.2 [MASKED] [MASKED] 05:45AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-138 K-3.6 Cl-105 HCO3-20* AnGap-17 [MASKED] 08:40PM BLOOD Glucose-108* UreaN-36* Creat-1.2* Na-138 K-3.7 Cl-105 HCO3-16* AnGap-21* [MASKED] 08:40PM BLOOD ALT-18 AST-16 AlkPhos-120* TotBili-0.3 [MASKED] 12:00PM BLOOD cTropnT-<0.01 [MASKED] 05:45AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 [MASKED] 08:40PM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.4 Mg-2.3 [MASKED] 10:02AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 10:02AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.3 LDLcalc-150* [MASKED] 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] CTA H&N Notable finding - Atherosclerotic vascular calcifications resulting in mild-to-moderate luminal narrowing of the petrous segment of the right ICA, similar to the prior study. Moderate luminal narrowing of the proximal to mid basilar artery again seen, likely atherosclerotic. [MASKED] MRI head w/o contrast - Acute to subacute infarction is seen involving the right parieto-occipital lobe, left parietal lobe, and right cerebellum. Possible punctate focus of infarction is seen within the left cerebellum. Distribution appears to be embolic in etiology. - Stable extensive confluent white matter changes, right greater than left temporal white matter, bilateral frontoparietal white matter as well as middle cerebellar peduncles likely combination of posttreatment changes and sequelae of chronic small vessel ischemic disease. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with PMH hypertension, carotid stenosis s/p R ICA stent, multiple prior strokes, CAD c/b MI, laryngeal cancer s/p surgery and radiation therapy who was admitted to Neurology stroke service with headache and dizziness. She was evaluated on telemetry and started on aspirin therapy. She was seen to have elevated LDL and due to previous statin intolerance was started on Zetia. She was seen on MRI to have ischemic stroke in the right parieto-occiptal lobe, left parietal lobe and left cerebellar lobe as well as moderate narrowing of basilar artery. These findings were suggestive of thrombotic etiology of her stroke. She underwent echocardiogram without concern. She was started on dual anti-platelet therapy with aspirin and Plavix. Her deficits (left visual field impairment, dysmetria) improved prior to discharge. She was discharged home with outpatient [MASKED] and [MASKED] services. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for secondary stroke prevention -pt will need to continue taking Zetia for hyperlipidemia -Will f/u pt's Echocardiogram final results; if anything concerning that is pertinent to patient's recent stroke, will contact pt to inform -Pt will need to f/u with PCP and [MASKED] [MASKED] on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation aerosol inhaler. [MASKED] puffs(s) inhaled every four (4) hours as needed for cough/wheeze/chest congestion/short of breath mdi with dose counter CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth twice daily - [MASKED] DC med rec) LEVOTHYROXINE - levothyroxine 100 mcg tablet. 1 tablet(s) by mouth once a day - [MASKED] DC med rec) LOSARTAN - losartan 50 mg tablet. 1 tablet(s) by mouth daily - [MASKED] DC med rec) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth qday SERTRALINE - sertraline 25 mg tablet. 1 tablet(s) by mouth - (Prescribed by Other Provider: per pt in [MASKED] Therapist f/u So End, w/plan for [MASKED] MD) (Not Taking as Prescribed: last filled in [MASKED]) TOPIRAMATE - topiramate 50 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider: [MASKED]. [MASKED] TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical cream. apply to rash, hands three times a day Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth daily - [MASKED] admission med rec) Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 2. Ezetimibe 10 mg PO DAILY RX *ezetimibe 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 3. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB 4. Carvedilol 12.5 mg PO BID 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Dao;u Disp #*30 Tablet Refills:*2 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of headache and dizziness 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 cholesterol We are changing your medications as follows: - Aspirin 81 mg daily (for stroke prevention) - Clopidegrel (Plavix) 75mg daily (for stroke prevention) - Ezetimibe (Zetia) 10mg daily (for cholesterol) 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]
[]
[ "N179", "I10", "I2510", "I252", "E039", "E785", "Z87891" ]
[ "I6302: Cerebral infarction due to thrombosis of basilar artery", "G9340: Encephalopathy, unspecified", "N179: Acute kidney failure, unspecified", "I6782: Cerebral ischemia", "I10: Essential (primary) hypertension", "R278: Other lack of coordination", "R51: Headache", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I69320: Aphasia following cerebral infarction", "I69398: Other sequelae of cerebral infarction", "I69393: Ataxia following cerebral infarction", "H5340: Unspecified visual field defects", "I252: Old myocardial infarction", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z8521: Personal history of malignant neoplasm of larynx", "Z87891: Personal history of nicotine dependence", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Z9114: Patient's other noncompliance with medication regimen", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,056,612
23,069,501
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Influenza Virus Vaccines Attending: ___. Chief Complaint: Episodes of confusion, dizziness, subjective lower extremity weakness and "out of body" experience Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ is a ___ year-old right-handed woman with PMH significant for laryngeal cancer s/p neck dissection and radiation therapy (___) with a chronic stable right temporal brain lesion felt to be radiation necrosis who presents with multiple transient episodes of ___ weakness, dysarthria and headache. The patient reports that the first of these episodes was in ___ (see Neurology ED consult note by ___ ___ The then restarted about 2 weeks ago (shortly after she missed a neurology appointment because she was at a court hearing - having her son evicted from her house and placed in an inpatient psych facility). She reports having about 5 events in the last 2 weeks with 2 today. She describes the events as follows: The onset always starts with a sense of dizziness - which she describes as a floating detached feeling "like im in the air" or "like I don't have a body". She denies a ___ out-of-body experience or vertigo. She then will feel "shaky" especially in her legs followed by a feeling of fear/anxiety. She feels like "I don't have any legs", describing them as numb and weak. Her speech will then sound funny. The event concludes in a non-pulsatile headache with nausea and occasional emesis. each event lasts about 10 min. She also describes a very similar episode (which she calls her stroke) at ___ in the months following her CA treatment. She denies any significant headache history. On neuro ROS: the pt denies loss of vision, blurred vision, diplopia, oscilopsia, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, paresthesias (outside of the events). No bowel or bladder incontinence or retention. Denies difficulty with gait. On general ROS: 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: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER ___, FOLLOWED AT ___ THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___ BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT ___ ? SEASONAL AFFECTIVE D/O ___: Admitted to ___ for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: ___ Family History: - Strong family history of malignancy. One brother deceased in his ___ with liver malignancy, another in his ___ with Lung Cancer. Mother deceased (reportedly at ___) in the setting of multiple medical problems plus a stroke. Her father died at ___. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION MEDICAL EXAMINATION T: 97.8 HR: 76 BP: 164/107 RR: 18 Sat: 99% on RA GENERAL MEDICAL EXAMINATION: General appearance: alert, in no apparent distress, conversing/interacting appropriately HEENT: Sclera are non-injected. Mucous membranes are moist. CV: Heart rate is regular Lungs: Breathing comfortably on RA Abdomen: soft, non-tender Extremities: No evidence of deformities. No contractures. No Edema. Skin: No visible rashes. Warm and well perfused. NEUROLOGICAL EXAMINATION: Mental Status: Alert and oriented to person place and time. Able to relate history without difficulty. Attentive to conversation. Language is fluent and appropriate with intact comprehension, repetition and naming of both high and low frequency objects. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. No neglect, left/right confusion or finger agnosia. During a witnessed event the patient's speech became slow and effortful but not dysarthric. She was still able to repeat and follow complex commands. She did not demonstrate any weakness during the event. Cranial Nerves: I: not tested II: visual fields full to confrontation III-IV-VI: pupils equally round, reactive to light. Normal conjugated, extra-ocular eye movements in all directions of gaze. No nystagmus or diplopia. V: Symmetric perception of LT in V1-3 VII: Face is symmetric at rest and with activation; symmetric speed and excursion with smile. VIII: Hearing intact to finger rub bl IX-X: Palate elevates symmetrically XI: Shoulder shrug ___ bl XII: No tongue deviation or fasciculations Motor: Normal muscle bulk and tone throughout. No pronator drift or rebound. Strength: 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 Reflexes: brisk and symmetric. Toes are equivocal bilaterally. Sensory: decreased perception to pin on the left (80%) (documented in prior exams). normal and symmetric perception of light touch, vibration and temperature. Proprioception is intact. Coordination: Finger to nose without dysmetria bilaterally. No intention tremor. RAM were slow but with regular cadence and good accuracy. Gait: Good initiation. Narrow-based, normal stride and arm swing. **DISCHARGE PHYSICAL EXAMINATION:** General: awake, alert woman in bed reporting mild headache in no acute distress HEENT: No conjunctival injection or discharge, MMM Resp: Breathing comfortably in room air CV: no cyanosis Abd: Non-distended Ext: WWP Neuro: Mental status: Awake, alert, oriented to place; conversant, able to answer basic history questions CN: PERRL, EOMI, face grossly symmetric with grossly normal facial sensation Motor: at least anti-gravity throughout with no orbiting Gait: deferred Pertinent Results: EEG: preliminary report (see full, final report for further details) multiple push button events without evidence of electrographic correlate (no evidence of seizure), no sharp waves; intermittent right temporal slowing as expected given known lesion ___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___ ___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___ ___ 01:00PM BLOOD WBC-4.4 RBC-5.08 Hgb-13.8 Hct-43.0 MCV-85 MCH-27.2 MCHC-32.1 RDW-15.7* RDWSD-47.8* Plt ___ ___ 06:50AM BLOOD Neuts-54.6 ___ Monos-8.8 Eos-1.7 Baso-0.7 Im ___ AbsNeut-2.22 AbsLymp-1.37 AbsMono-0.36 AbsEos-0.07 AbsBaso-0.03 ___ 01:00PM BLOOD Neuts-58.3 ___ Monos-9.1 Eos-1.8 Baso-0.7 Im ___ AbsNeut-2.56 AbsLymp-1.29 AbsMono-0.40 AbsEos-0.08 AbsBaso-0.03 ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD ___ PTT-30.8 ___ ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD ___ PTT-29.5 ___ ___ 06:50AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-141 K-3.5 Cl-104 HCO3-26 AnGap-15 ___ 01:00PM BLOOD Glucose-89 UreaN-21* Creat-1.1 Na-137 K-4.8 Cl-97 HCO3-29 AnGap-16 ___ 06:50AM BLOOD ALT-20 AST-25 LD(LDH)-212 AlkPhos-95 TotBili-0.6 ___ 06:50AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 ___ 06:50AM BLOOD TSH-36* ___ 01:06PM BLOOD Lactate-1.2 Brief Hospital Course: Patient was admitted to the Neurology Service where she was placed on long term EEG to capture events. Multiple episodes were captured and were typical of the events of interest. There were multiple push button events for these episodes without EEG correlate (no evidence of seizure). As a result, these episodes were felt to be most likely due to stress (e.g. possible panic attacks). No medication changes were made, and no new medications were added. She was discharged home with a plan to follow up with her primary care physician, ___, and psychiatry. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: non focal Discharge Instructions: Dear Ms. ___, You were admitted for episodes of feeling dizzy, confused, "floating" and scared. We placed you on EEG to look at your brain waves. You had a few of these episodes while under EEG monitoring and they were not seizures. We think that your episodes are most likely from anxiety. Please talk to your primary care doctor to arrange for a psychiatry appointment for management of your anxiety. Followup Instructions: ___
[ "F410", "I6782", "D649", "F430", "Z91419", "F329", "I2510", "I10", "E780", "Z87891", "Y842", "Z8521", "Z801", "Z808", "Z8673" ]
Allergies: Influenza Virus Vaccines Chief Complaint: Episodes of confusion, dizziness, subjective lower extremity weakness and "out of body" experience Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] is a [MASKED] year-old right-handed woman with PMH significant for laryngeal cancer s/p neck dissection and radiation therapy ([MASKED]) with a chronic stable right temporal brain lesion felt to be radiation necrosis who presents with multiple transient episodes of [MASKED] weakness, dysarthria and headache. The patient reports that the first of these episodes was in [MASKED] (see Neurology ED consult note by [MASKED] [MASKED] The then restarted about 2 weeks ago (shortly after she missed a neurology appointment because she was at a court hearing - having her son evicted from her house and placed in an inpatient psych facility). She reports having about 5 events in the last 2 weeks with 2 today. She describes the events as follows: The onset always starts with a sense of dizziness - which she describes as a floating detached feeling "like im in the air" or "like I don't have a body". She denies a [MASKED] out-of-body experience or vertigo. She then will feel "shaky" especially in her legs followed by a feeling of fear/anxiety. She feels like "I don't have any legs", describing them as numb and weak. Her speech will then sound funny. The event concludes in a non-pulsatile headache with nausea and occasional emesis. each event lasts about 10 min. She also describes a very similar episode (which she calls her stroke) at [MASKED] in the months following her CA treatment. She denies any significant headache history. On neuro ROS: the pt denies loss of vision, blurred vision, diplopia, oscilopsia, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, paresthesias (outside of the events). No bowel or bladder incontinence or retention. Denies difficulty with gait. On general ROS: 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: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy [MASKED] years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER [MASKED], FOLLOWED AT [MASKED] THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, [MASKED] BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT [MASKED] ? SEASONAL AFFECTIVE D/O [MASKED]: Admitted to [MASKED] for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: [MASKED] Family History: - Strong family history of malignancy. One brother deceased in his [MASKED] with liver malignancy, another in his [MASKED] with Lung Cancer. Mother deceased (reportedly at [MASKED]) in the setting of multiple medical problems plus a stroke. Her father died at [MASKED]. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION MEDICAL EXAMINATION T: 97.8 HR: 76 BP: 164/107 RR: 18 Sat: 99% on RA GENERAL MEDICAL EXAMINATION: General appearance: alert, in no apparent distress, conversing/interacting appropriately HEENT: Sclera are non-injected. Mucous membranes are moist. CV: Heart rate is regular Lungs: Breathing comfortably on RA Abdomen: soft, non-tender Extremities: No evidence of deformities. No contractures. No Edema. Skin: No visible rashes. Warm and well perfused. NEUROLOGICAL EXAMINATION: Mental Status: Alert and oriented to person place and time. Able to relate history without difficulty. Attentive to conversation. Language is fluent and appropriate with intact comprehension, repetition and naming of both high and low frequency objects. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. No neglect, left/right confusion or finger agnosia. During a witnessed event the patient's speech became slow and effortful but not dysarthric. She was still able to repeat and follow complex commands. She did not demonstrate any weakness during the event. Cranial Nerves: I: not tested II: visual fields full to confrontation III-IV-VI: pupils equally round, reactive to light. Normal conjugated, extra-ocular eye movements in all directions of gaze. No nystagmus or diplopia. V: Symmetric perception of LT in V1-3 VII: Face is symmetric at rest and with activation; symmetric speed and excursion with smile. VIII: Hearing intact to finger rub bl IX-X: Palate elevates symmetrically XI: Shoulder shrug [MASKED] bl XII: No tongue deviation or fasciculations Motor: Normal muscle bulk and tone throughout. No pronator drift or rebound. Strength: 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 Reflexes: brisk and symmetric. Toes are equivocal bilaterally. Sensory: decreased perception to pin on the left (80%) (documented in prior exams). normal and symmetric perception of light touch, vibration and temperature. Proprioception is intact. Coordination: Finger to nose without dysmetria bilaterally. No intention tremor. RAM were slow but with regular cadence and good accuracy. Gait: Good initiation. Narrow-based, normal stride and arm swing. **DISCHARGE PHYSICAL EXAMINATION:** General: awake, alert woman in bed reporting mild headache in no acute distress HEENT: No conjunctival injection or discharge, MMM Resp: Breathing comfortably in room air CV: no cyanosis Abd: Non-distended Ext: WWP Neuro: Mental status: Awake, alert, oriented to place; conversant, able to answer basic history questions CN: PERRL, EOMI, face grossly symmetric with grossly normal facial sensation Motor: at least anti-gravity throughout with no orbiting Gait: deferred Pertinent Results: EEG: preliminary report (see full, final report for further details) multiple push button events without evidence of electrographic correlate (no evidence of seizure), no sharp waves; intermittent right temporal slowing as expected given known lesion [MASKED] 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt [MASKED] [MASKED] 01:00PM BLOOD WBC-4.4 RBC-5.08 Hgb-13.8 Hct-43.0 MCV-85 MCH-27.2 MCHC-32.1 RDW-15.7* RDWSD-47.8* Plt [MASKED] [MASKED] 06:50AM BLOOD Neuts-54.6 [MASKED] Monos-8.8 Eos-1.7 Baso-0.7 Im [MASKED] AbsNeut-2.22 AbsLymp-1.37 AbsMono-0.36 AbsEos-0.07 AbsBaso-0.03 [MASKED] 01:00PM BLOOD Neuts-58.3 [MASKED] Monos-9.1 Eos-1.8 Baso-0.7 Im [MASKED] AbsNeut-2.56 AbsLymp-1.29 AbsMono-0.40 AbsEos-0.08 AbsBaso-0.03 [MASKED] 06:50AM BLOOD Plt [MASKED] [MASKED] 06:50AM BLOOD [MASKED] PTT-30.8 [MASKED] [MASKED] 01:00PM BLOOD Plt [MASKED] [MASKED] 01:00PM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 06:50AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-141 K-3.5 Cl-104 HCO3-26 AnGap-15 [MASKED] 01:00PM BLOOD Glucose-89 UreaN-21* Creat-1.1 Na-137 K-4.8 Cl-97 HCO3-29 AnGap-16 [MASKED] 06:50AM BLOOD ALT-20 AST-25 LD(LDH)-212 AlkPhos-95 TotBili-0.6 [MASKED] 06:50AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 [MASKED] 06:50AM BLOOD TSH-36* [MASKED] 01:06PM BLOOD Lactate-1.2 Brief Hospital Course: Patient was admitted to the Neurology Service where she was placed on long term EEG to capture events. Multiple episodes were captured and were typical of the events of interest. There were multiple push button events for these episodes without EEG correlate (no evidence of seizure). As a result, these episodes were felt to be most likely due to stress (e.g. possible panic attacks). No medication changes were made, and no new medications were added. She was discharged home with a plan to follow up with her primary care physician, [MASKED], and psychiatry. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: non focal Discharge Instructions: Dear Ms. [MASKED], You were admitted for episodes of feeling dizzy, confused, "floating" and scared. We placed you on EEG to look at your brain waves. You had a few of these episodes while under EEG monitoring and they were not seizures. We think that your episodes are most likely from anxiety. Please talk to your primary care doctor to arrange for a psychiatry appointment for management of your anxiety. Followup Instructions: [MASKED]
[]
[ "D649", "F329", "I2510", "I10", "Z87891", "Z8673" ]
[ "F410: Panic disorder [episodic paroxysmal anxiety]", "I6782: Cerebral ischemia", "D649: Anemia, unspecified", "F430: Acute stress reaction", "Z91419: Personal history of unspecified adult abuse", "F329: Major depressive disorder, single episode, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E780: Pure hypercholesterolemia", "Z87891: Personal history of nicotine dependence", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Z8521: Personal history of malignant neoplasm of larynx", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z808: Family history of malignant neoplasm of other organs or systems", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,056,612
24,412,612
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / clopidogrel / lisinopril / chlorthalidone Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ yo female with a history of laryngeal cancer and a right temporal mass who is admitted with headaches and hypertensive urgency. The patient states she has been having intermittent headaches, weakness, nausea, and vision changes for three days. She denies any fevers, shortness of breath, diarrhea, constipation, dysuria, or rashes. She states she is taking carvedilol twice a day and atenolol once a day for her blood pressure. She reports not taking losartan. She does seem confused about her medications and per report her daughter also is concern about her management of medications at home. She reportedly lives with her son who is bipolar and causes he significant stress. She presented to the ED on ___ and was found to be hyptertensive. A head CT was done and unchanged from prior and she was sent home. In the ED this evening she was again found to be hypertensive to 200s/100s. She was given carvedilol with improvement in her blood pressure. On arrival to the floor she states that her headache and other symptoms have significantly improved. Past Medical History: Laryngeal cancer, ___ CVA/TIA Hypertension HLD Hypothyroidism after thyroid surgery for nodule ___ stenosis status post right carotid stents Cervical cancer, hysterectomy Tonsilectomy Appendectomy Right ankle fracture, pins placed Bilateral cataracts Social History: ___ Family History: She had two brothers, one died in his ___ with liver cancer and one died in his ___ with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION EXAM: =============== General: NAD VITAL SIGNS: T 97.3 BP 149/68 HR 61 RR 16 O2 97%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits, Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed; strength is ___ of the proximal and distal upper and lower extremities. DISCHARGE EXAM: =============== VITAL SIGNS: T 98.6 BP 128/60 HR 76 RR 18 O2 98%RA General: Pleasant, animated woman, sitting up comfortably in bed. HEENT: MMM, no nystagmus. PERLL. EOMI. OP clear. CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No edema, normal bulk, wwp SKIN: No rashes on extremities NEURO: Alert and interactive. Oriented x3. No focal weakness including symmetric ___ upper extremity strength and ___ lower extremity strength. FTN intact. CN III-XII intact. Pertinent Results: ADMISSION LABS: ============== ___ 09:40PM BLOOD WBC-4.1 RBC-4.44 Hgb-12.2 Hct-38.9 MCV-88 MCH-27.5 MCHC-31.4* RDW-14.4 RDWSD-46.0 Plt ___ ___ 09:40PM BLOOD Neuts-51.4 ___ Monos-10.0 Eos-2.7 Baso-0.5 Im ___ AbsNeut-2.10 AbsLymp-1.42 AbsMono-0.41 AbsEos-0.11 AbsBaso-0.02 ___ 09:40PM BLOOD Plt ___ ___ 09:40PM BLOOD Glucose-87 UreaN-21* Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-24 AnGap-16 ___ 07:44AM BLOOD ALT-21 AST-19 LD(LDH)-179 AlkPhos-108* TotBili-<0.2 ___ 09:40PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1 ___ 10:15PM BLOOD CRP-3.0 DISCHARGE LABS: =============== ___ 07:44AM BLOOD WBC-4.6 RBC-4.16 Hgb-11.5 Hct-35.8 MCV-86 MCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3* Plt ___ ___ 07:18AM BLOOD Glucose-77 UreaN-25* Creat-0.8 Na-141 K-3.7 Cl-112* HCO3-18* AnGap-15 ___ 07:18AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 IMAGING: ======== ___ Imaging MRV HEAD W/O CONTRAST 1. No evidence of cerebral venous thrombosis. 2. Unchanged 13 x 7 mm enhancing right middle cranial fossa extra-axial lesion. 3. Previously noted subtle area of right medial occipital leptomeningeal enhancement is not well appreciated on the current examination, likely due to difference in technique. 4. No new enhancing lesion. 5. Multiple chronic infarcts, as described. 6. Confluent areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease. ___ Imaging MR HEAD W & W/O CONTRAS 1. New small evolving acute or early subacute infarct within the left posterior inferior cerebellar hemisphere. 2. Stable enhancing extraaxial mass along the medial right temporal lobe. 3. Stable small area of leptomeningeal enhancement along the medial right occipital lobe dating back to ___, etiology uncertain. 4. Stable chronic infarctions within bilateral cerebellar hemispheres and left pons. 5. Stable extensive confluent white matter changes in right greater than left temporal white matter, and bilateral frontal and parietal white matter, as well as in the middle cerebellar peduncles and bilateral pons, likely a combination of posttreatment changes and sequela of chronic small vessel ischemic disease. 6. Stable left frontal developmental venous anomaly. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ w/ CAD, TIA, HTN, DL, brainstem CVA, h/o submandibular cystic carcinoma, diagnosed in ___, followed by modified radical neck dissection, R temporal mass (most likely XRT necrosis) stable since ___, carotid stenosis s/p ___ stents, and history of hypertensive emergency causing headaches due to medication noncompliance, p/w HA dizziness and nausea, found to have hypertensive emergency and new cerebellar CVA. Now with persistent/intractable headache. # Hypertensive emergency: # Hypertension: Etiology of hypertensive emergency thought due to noncompliance of her home medications, and she improved with resumption of home carvedilol 12.5 and losartan 50. However, her headache persisted, and after staring IV dexamethasone, her blood pressures again worsened. We uptitrated her carvedilol to 25mg bid and increased losartan to 100mg daily. She continued to require intermittent po labetolol and IV hydralazine. On ___ we restarted her on chlorthalidone 25mg daily (she had previously taken this, but was stopped due to urinary frequency). Day of discharge blood pressure was better controlled in the 120's-130's. She was discharged with these medications and po potassium 10 meq daily. She should have blood pressure and chemistry panel checked on ___ consider investigating secondary causes of hypertension, at her primary team's discretion. # Stroke: Etiology thought from HTN disease. 48 hours of telemetry were unremarkable and prior carotid imaging was normal. Last LDL ___ was 124; last A1c 5.5%. No clear/focal neurologic deficits despite new CVA on imaging. Patient was previously on ASA and plavix but she discontinued plavix due to dizziness some time ago. Unclear if she was taking ASA at home. We restarted Plavix. Statin was held given patient's reported statin allergy, although this should continually be discussed with her PCP. # Persistent L sided HA # Status migranosis: Etiology of headache initially thought due to uncontrolled HTN. However, headaches persisted despite better BP. Head MRI revealed small Cerebellar ischemic stroke, as above, which was out of proportion to her headaches. MRV was negative for venous thrombosis. CRP/ESR not indicative of temporal arteritis. Deferred LP given no suspicion for infection. She was initially treated with fioricet and tramadol. Received small amounts of IV morphine. Ulitmately opiods and tramadol limited due to concern for rebound headache/overuse headache. She was given 3 days of IV dexamethasone starting ___ and started acetazolamide 500mg twice daily on ___. Headache broke on evening of ___ and patient was discharged pain free. She will continue acetazolamide indefinitely per her neuro-oncologist, Dr. ___ should follow up with him in ~2 weeks. # Metabolic acidosis: Patient developed non-gap hyperchloremic metabolic acidosis, likely due to acetazolamide. Will continue acetazolamide and continue to monitor. # Hypothyroidism: Continued home synthroid. Last TSH 30, rechecked TSH here and 0.3 # GERD: Continued home omeprazole. # Social: On admission there was some concern regarding patient's safety at home. SW was consulted and safe discharge plan was developed. Ultimately felt to be safe for home discharge in light of her extensive support system and ability to call ___ should there be an emergency. This plan was made in accordance to the patient's wishes, as well. Please see SW noted for further information. # Billing: >30 minutes spent planning and executing this discharge plan TRANSITIONAL ISSUES: =================== - Close monitoring of blood pressures and medication compliance - Increased losartan to 100mg daily and carvedilol to 25mg twice daily - Started chlorthalidone 25mg daily on ___ and discharged with 10meq potassium supplements - Please recheck Chemistry on ___ - Resumed Plavix. Currently holding aspirin - Discuss statin use with patient given recurrence cerebrovascular disease Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Topiramate (Topamax) 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Aspirin 81 mg PO DAILY 6. Carvedilol 12.5 mg PO BID 7. Atenolol Dose is Unknown PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Losartan Potassium 50 mg PO DAILY Discharge Medications: 1. AcetaZOLamide 500 mg PO Q12H RX *acetazolamide 500 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Potassium Chloride 10 mEq PO DAILY Hold for K > RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Losartan Potassium 100 mg PO DAILY RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 650 mg 1 tablet(s) by mouth q6 hours Disp #*60 Tablet Refills:*0 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff IH q4 hours Disp #*1 Inhaler Refills:*0 9. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 11. Topiramate (Topamax) 50 mg PO DAILY RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CVA Hypertensive Emergency Status Migraine Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you at ___ ___. You were admitted for severe headaches. You were found to have a hypertensive emergency and your blood pressures improved with restarting your home carvedilol and losartan. We ultimately increased your carvedilol and losartan doses and started an new medication called chlorthalidone. You cannot miss these medications, and you must follow up with Dr. ___ very close monitoring of your blood pressure and blood work. Additionally, ___ had a brain MRI which revealed a small stroke. You continued to have very severe headaches, so we gave you a three day course of IV dexamethasone (steroids) and started a medication called acetazolamide. You will need to follow up with Drs. ___. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "I161", "I639", "E872", "Z87891", "G43901", "E039", "K219", "Z8673", "Z8521", "Z8541" ]
Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / clopidogrel / lisinopril / chlorthalidone Chief Complaint: headache Major Surgical or Invasive Procedure: N/A History of Present Illness: [MASKED] yo female with a history of laryngeal cancer and a right temporal mass who is admitted with headaches and hypertensive urgency. The patient states she has been having intermittent headaches, weakness, nausea, and vision changes for three days. She denies any fevers, shortness of breath, diarrhea, constipation, dysuria, or rashes. She states she is taking carvedilol twice a day and atenolol once a day for her blood pressure. She reports not taking losartan. She does seem confused about her medications and per report her daughter also is concern about her management of medications at home. She reportedly lives with her son who is bipolar and causes he significant stress. She presented to the ED on [MASKED] and was found to be hyptertensive. A head CT was done and unchanged from prior and she was sent home. In the ED this evening she was again found to be hypertensive to 200s/100s. She was given carvedilol with improvement in her blood pressure. On arrival to the floor she states that her headache and other symptoms have significantly improved. Past Medical History: Laryngeal cancer, [MASKED] CVA/TIA Hypertension HLD Hypothyroidism after thyroid surgery for nodule [MASKED] stenosis status post right carotid stents Cervical cancer, hysterectomy Tonsilectomy Appendectomy Right ankle fracture, pins placed Bilateral cataracts Social History: [MASKED] Family History: She had two brothers, one died in his [MASKED] with liver cancer and one died in his [MASKED] with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION EXAM: =============== General: NAD VITAL SIGNS: T 97.3 BP 149/68 HR 61 RR 16 O2 97%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits, Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed; strength is [MASKED] of the proximal and distal upper and lower extremities. DISCHARGE EXAM: =============== VITAL SIGNS: T 98.6 BP 128/60 HR 76 RR 18 O2 98%RA General: Pleasant, animated woman, sitting up comfortably in bed. HEENT: MMM, no nystagmus. PERLL. EOMI. OP clear. CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No edema, normal bulk, wwp SKIN: No rashes on extremities NEURO: Alert and interactive. Oriented x3. No focal weakness including symmetric [MASKED] upper extremity strength and [MASKED] lower extremity strength. FTN intact. CN III-XII intact. Pertinent Results: ADMISSION LABS: ============== [MASKED] 09:40PM BLOOD WBC-4.1 RBC-4.44 Hgb-12.2 Hct-38.9 MCV-88 MCH-27.5 MCHC-31.4* RDW-14.4 RDWSD-46.0 Plt [MASKED] [MASKED] 09:40PM BLOOD Neuts-51.4 [MASKED] Monos-10.0 Eos-2.7 Baso-0.5 Im [MASKED] AbsNeut-2.10 AbsLymp-1.42 AbsMono-0.41 AbsEos-0.11 AbsBaso-0.02 [MASKED] 09:40PM BLOOD Plt [MASKED] [MASKED] 09:40PM BLOOD Glucose-87 UreaN-21* Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-24 AnGap-16 [MASKED] 07:44AM BLOOD ALT-21 AST-19 LD(LDH)-179 AlkPhos-108* TotBili-<0.2 [MASKED] 09:40PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1 [MASKED] 10:15PM BLOOD CRP-3.0 DISCHARGE LABS: =============== [MASKED] 07:44AM BLOOD WBC-4.6 RBC-4.16 Hgb-11.5 Hct-35.8 MCV-86 MCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3* Plt [MASKED] [MASKED] 07:18AM BLOOD Glucose-77 UreaN-25* Creat-0.8 Na-141 K-3.7 Cl-112* HCO3-18* AnGap-15 [MASKED] 07:18AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 IMAGING: ======== [MASKED] Imaging MRV HEAD W/O CONTRAST 1. No evidence of cerebral venous thrombosis. 2. Unchanged 13 x 7 mm enhancing right middle cranial fossa extra-axial lesion. 3. Previously noted subtle area of right medial occipital leptomeningeal enhancement is not well appreciated on the current examination, likely due to difference in technique. 4. No new enhancing lesion. 5. Multiple chronic infarcts, as described. 6. Confluent areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease. [MASKED] Imaging MR HEAD W & W/O CONTRAS 1. New small evolving acute or early subacute infarct within the left posterior inferior cerebellar hemisphere. 2. Stable enhancing extraaxial mass along the medial right temporal lobe. 3. Stable small area of leptomeningeal enhancement along the medial right occipital lobe dating back to [MASKED], etiology uncertain. 4. Stable chronic infarctions within bilateral cerebellar hemispheres and left pons. 5. Stable extensive confluent white matter changes in right greater than left temporal white matter, and bilateral frontal and parietal white matter, as well as in the middle cerebellar peduncles and bilateral pons, likely a combination of posttreatment changes and sequela of chronic small vessel ischemic disease. 6. Stable left frontal developmental venous anomaly. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: [MASKED] w/ CAD, TIA, HTN, DL, brainstem CVA, h/o submandibular cystic carcinoma, diagnosed in [MASKED], followed by modified radical neck dissection, R temporal mass (most likely XRT necrosis) stable since [MASKED], carotid stenosis s/p [MASKED] stents, and history of hypertensive emergency causing headaches due to medication noncompliance, p/w HA dizziness and nausea, found to have hypertensive emergency and new cerebellar CVA. Now with persistent/intractable headache. # Hypertensive emergency: # Hypertension: Etiology of hypertensive emergency thought due to noncompliance of her home medications, and she improved with resumption of home carvedilol 12.5 and losartan 50. However, her headache persisted, and after staring IV dexamethasone, her blood pressures again worsened. We uptitrated her carvedilol to 25mg bid and increased losartan to 100mg daily. She continued to require intermittent po labetolol and IV hydralazine. On [MASKED] we restarted her on chlorthalidone 25mg daily (she had previously taken this, but was stopped due to urinary frequency). Day of discharge blood pressure was better controlled in the 120's-130's. She was discharged with these medications and po potassium 10 meq daily. She should have blood pressure and chemistry panel checked on [MASKED] consider investigating secondary causes of hypertension, at her primary team's discretion. # Stroke: Etiology thought from HTN disease. 48 hours of telemetry were unremarkable and prior carotid imaging was normal. Last LDL [MASKED] was 124; last A1c 5.5%. No clear/focal neurologic deficits despite new CVA on imaging. Patient was previously on ASA and plavix but she discontinued plavix due to dizziness some time ago. Unclear if she was taking ASA at home. We restarted Plavix. Statin was held given patient's reported statin allergy, although this should continually be discussed with her PCP. # Persistent L sided HA # Status migranosis: Etiology of headache initially thought due to uncontrolled HTN. However, headaches persisted despite better BP. Head MRI revealed small Cerebellar ischemic stroke, as above, which was out of proportion to her headaches. MRV was negative for venous thrombosis. CRP/ESR not indicative of temporal arteritis. Deferred LP given no suspicion for infection. She was initially treated with fioricet and tramadol. Received small amounts of IV morphine. Ulitmately opiods and tramadol limited due to concern for rebound headache/overuse headache. She was given 3 days of IV dexamethasone starting [MASKED] and started acetazolamide 500mg twice daily on [MASKED]. Headache broke on evening of [MASKED] and patient was discharged pain free. She will continue acetazolamide indefinitely per her neuro-oncologist, Dr. [MASKED] should follow up with him in ~2 weeks. # Metabolic acidosis: Patient developed non-gap hyperchloremic metabolic acidosis, likely due to acetazolamide. Will continue acetazolamide and continue to monitor. # Hypothyroidism: Continued home synthroid. Last TSH 30, rechecked TSH here and 0.3 # GERD: Continued home omeprazole. # Social: On admission there was some concern regarding patient's safety at home. SW was consulted and safe discharge plan was developed. Ultimately felt to be safe for home discharge in light of her extensive support system and ability to call [MASKED] should there be an emergency. This plan was made in accordance to the patient's wishes, as well. Please see SW noted for further information. # Billing: >30 minutes spent planning and executing this discharge plan TRANSITIONAL ISSUES: =================== - Close monitoring of blood pressures and medication compliance - Increased losartan to 100mg daily and carvedilol to 25mg twice daily - Started chlorthalidone 25mg daily on [MASKED] and discharged with 10meq potassium supplements - Please recheck Chemistry on [MASKED] - Resumed Plavix. Currently holding aspirin - Discuss statin use with patient given recurrence cerebrovascular disease Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN sob 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Topiramate (Topamax) 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Aspirin 81 mg PO DAILY 6. Carvedilol 12.5 mg PO BID 7. Atenolol Dose is Unknown PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Losartan Potassium 50 mg PO DAILY Discharge Medications: 1. AcetaZOLamide 500 mg PO Q12H RX *acetazolamide 500 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Potassium Chloride 10 mEq PO DAILY Hold for K > RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Losartan Potassium 100 mg PO DAILY RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 650 mg 1 tablet(s) by mouth q6 hours Disp #*60 Tablet Refills:*0 8. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN sob RX *albuterol sulfate [ProAir HFA] 90 mcg [MASKED] puff IH q4 hours Disp #*1 Inhaler Refills:*0 9. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 11. Topiramate (Topamax) 50 mg PO DAILY RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: CVA Hypertensive Emergency Status Migraine Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted for severe headaches. You were found to have a hypertensive emergency and your blood pressures improved with restarting your home carvedilol and losartan. We ultimately increased your carvedilol and losartan doses and started an new medication called chlorthalidone. You cannot miss these medications, and you must follow up with Dr. [MASKED] very close monitoring of your blood pressure and blood work. Additionally, [MASKED] had a brain MRI which revealed a small stroke. You continued to have very severe headaches, so we gave you a three day course of IV dexamethasone (steroids) and started a medication called acetazolamide. You will need to follow up with Drs. [MASKED]. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E872", "Z87891", "E039", "K219", "Z8673" ]
[ "I161: Hypertensive emergency", "I639: Cerebral infarction, unspecified", "E872: Acidosis", "Z87891: Personal history of nicotine dependence", "G43901: Migraine, unspecified, not intractable, with status migrainosus", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z8521: Personal history of malignant neoplasm of larynx", "Z8541: Personal history of malignant neoplasm of cervix uteri" ]
10,056,612
26,462,956
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines Attending: ___. Chief Complaint: Headache, dizziness, nausea. Major Surgical or Invasive Procedure: There were no major surgical or invasive procedures during hospitalization. History of Present Illness: ___ year who was sent in by ___ on ___ after experiencing headache and emesis. The headache was acute in onset however no headstrike or injuries were reported. She also developed bilateral lower extremity weakness requiring her to have to walk as she was unsteady on her feet. There was concern regarding her presentation as she experienced similar symptoms when she had a prior stroke. In the ED, initial vitals were: Pain 8, Temperature 96.8, HR 101, BP 155/93, RR 16, Pulse Ox 99% on RA. Urine/serum toxicology screen was negative. UA was negative. Chemistry panel was normal except for a BUN of 24. LFT's were normal except for an alk phos of 144. CBC was within normal limits. She underwent a CTA head and neck with preliminary reading showing "no flow limiting stenosis in the intracranial and cervical vessels. No evidence of aneurysm greater than 3 mm or dissection. Patent stent graft in the right common carotid artery. Calcified and non-calcified plaque at the left carotid bifurcation causing mild narrowing. Atherosclerotic calcification involving the left greater than right cervical vertebral arteries. Severe atherosclerotic disease of the aortic arch and descending aorta with both calcified and non-calcified plaque. Unchanged 8 mm right upper lobe pulmonary nodule, follow up per prior chest CT's." The patient was evaluated by neurology who suspected that the patient's current presentation was due to sub-acute spinal pathology coupled with ongoing medical illness and stress due to home situation. The patient was evaluated by ___ in the ED who recommended ___ visits or discharge to rehab. The patient was admitted to medicine for coordination of care and symptomatic management. On the floor, the patient reports improvement in her nausea and abdominal pain. She has some persistent left lower extremity weakness compared to right. She reports intermittent dizziness which she describes as the sensation that the room is spinning around her. She reports stress regarding her son and his issues with addiction, which she has dealt with for some time. She reported headache on presentation bi-temporal, which has improved. The patient does not remember the exact events when she was walking to her closet yesterday morning, but she did not experience any prodromal symptoms, nor changes in vision. Past Medical History: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER ___, FOLLOWED AT ___ THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___ BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT ___ ? SEASONAL AFFECTIVE D/O ___: Admitted to ___ for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: ___ Family History: - Strong family history of malignancy. One brother deceased in his ___ with liver malignancy, another in his ___ with Lung Cancer. Mother deceased (reportedly at ___) in the setting of multiple medical problems plus a stroke. Her father died at ___. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 97.1, 138/70, 64, 18, 98% on RA General: alert, oriented, tearful when discussing son, otherwise not in acute distress HEENT: pale conjunctiva, JVP not visualized, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation, no oropharnygeal lesions visualized CV: RRR, nl S1 S2, no murmurs, rubs, gallops; no carotid bruit b/l Lungs: CTA b/l, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact (though patient refuses to extend tongue for testing of CN12), ___ strength upper/lower extremities, grossly normal sensation, upgoing babinskin on left, downgoing on right, gait deferred, ___ negative b/l, mild left lateral end-gaze nystagmus DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.2 ___ 44-70 18 95-100%RA General: AOx3, lying in bed, appears comfortable, very pleasant HEENT: MMM, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation CV: RRR, normal S1 and S2 no m/r/g. Lungs: Clear to auscultation bilaterally. Abdomen: soft, nt, nd, no rebound or guarding. Ext: Warm, well perfused, no edema. Neuro: AOx3, EOMI, CNII-XII intact, strength/sensation grossly intact Pertinent Results: ADMISSION LABS ============== ___ 01:45PM BLOOD WBC-4.6 RBC-5.18 Hgb-13.8 Hct-43.4 MCV-84 MCH-26.6 MCHC-31.8* RDW-16.2* RDWSD-49.3* Plt ___ ___ 01:45PM BLOOD Neuts-67.6 ___ Monos-7.4 Eos-0.4* Baso-0.7 Im ___ AbsNeut-3.10 AbsLymp-1.08* AbsMono-0.34 AbsEos-0.02* AbsBaso-0.03 ___ 01:45PM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-140 K-3.8 Cl-101 HCO3-29 AnGap-14 ___ 01:45PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.9 Mg-2.1 ___ 01:45PM BLOOD ALT-31 AST-26 AlkPhos-144* TotBili-0.4 DISCHARGE LABS ============== ___ 07:32AM BLOOD WBC-3.8* RBC-5.17 Hgb-13.7 Hct-42.5 MCV-82 MCH-26.5 MCHC-32.2 RDW-16.2* RDWSD-48.2* Plt ___ ___ 07:32AM BLOOD Glucose-95 UreaN-17 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-29 AnGap-13 ___ 07:32AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0 SERUM TOXICOLOGY ================ ___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE TOXICOLOGY ================ ___ 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE STUDIES ============= ___ 03:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ======= ___: CTA HEAD AND CTA NECK IMPRESSION: 1. Extensive periventricular and subcortical white matter hypodensities, relatively unchanged compared to the prior MRI allowing for the differences in technique. Please note that evaluation for an underlying acute infarct is limited given the extensive hypodensities. MRI of the brain can be performed for further evaluation as clinically indicated. 2. Vasogenic edema in the inferior right temporal lobe. The previously known enhancing lesion in the right temporal lobe is not well visualized on the CT scan. 3. Patent right internal and common carotid artery stent. 4. Atherosclerosis involving the left carotid bifurcation without any stenosis by NASCET criteria. 5. Atherosclerosis involving V2 segment of left vertebral artery causing focal areas of mild luminal narrowing. 6. Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. ___: PELVIS (AP ONLY) FINDINGS: No fracture or dislocation. Bilateral hip joint spaces are relatively well preserved with only minimal degenerative change. Pubic symphysis and SI joints are preserved. No radiopaque foreign body. Contrast is seen within the bladder. IMPRESSION: No fracture or dislocation. Brief Hospital Course: ASSESSMENT AND PLAN: ___ with PMH of HTN, hypothyroidism, head and neck cancer s/p neck dissection x2 who presented with complaints of vertigo and leg weakness after fall with complex social situation concerning for abuse. # Vertigo secondary to BPPV versus Social Stressors/Anxiety: Ms. ___ presented with nausea and dizziness. Based on description it appeared the vertigo appeared to be position in nature. Given her history of carotid stenosis, a CTA head and neck was obtained which did not show any evidence of new acute stroke. Neurology was consulted during hospitalization who did not believe symptoms could be explained by an acute stroke. Rather, they believed the symptoms were consistent with benign paroxysmal positional vertigo as neurologic exam was completely benign. During hospitalization, it was also noted that Ms. ___ symptoms occurred when she was talking about her stressful home situation (a son at home who has a drug addiction and is verbally abusive to her). When talking to her son on the phone, Ms. ___ would experience the dizziness and nausea. She also experienced these symptoms when she described her stressful home situation to the medical team. These symptoms would resolve after she had time to relax. Neurology did not believe any further work-up was necessary as an inpatient and recommended follow up with her Neurologist, Dr. ___. # Social Stressors/Verbal Abuse: Ms. ___ described her stressful home situation with her son. She describes her son as addicted to crack. She also described numerous episodes of verbal abuse to her. She denied any physical abuse. Elder services had been involved in the past. Given this description, social work was heavily involved during this hospitalization and initial mandated reporting was done upon admission. She was hesitant to be discharged from the hospital until ___ discharge plan was in place. Social work attempted to find other places for her to stay, however, patient elected to be discharged home. To facilitate a safe discharge plan, plans were made with ___ Police if any abuse at home (plan would be contact Police at Precinct B2 with ___ ___ ___ cell). These plans were also communicated with patient's daughter (___) to instruct on when to call the police. Prior to her discharge, Elder Protective Services were called for wellness and home safety evaluations to occur at home. Ms. ___ was able to voice back the safety plan that was developed and reported she felt comfortable with the safety plan. Attempts were made to locate safe housing prior to discharge,but patient denied further services. # Bacterial pneumonia: patient recently diagnosed with atypical pneumonia at PCP, started on course of levofloxacin ___. She completed her 10 day course of levofloxacin on ___. She was not experience cough or fever, and remained hemodynamically stable during hospitalization. # Hypertension: Continued atenolol, chlorthalidone, and aspirin during hospitalization. # Hypothyroidism: Continued levothyroxine during hospitalization. TRANSITIONAL ISSUES =================== - Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. Of note, this lesion has been documented on previous CT scans of the chest. - CTA Head and Neck: Marked atherosclerosis involving the aortic arch with penetrating atherosclerotic ulcer as seen on image 5:27. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. - Please continue to follow up with patient's safety situation at home - If further concerns for elder abuse, please contact Elder Services. - Patient was noted to have mild leukopenia on labs. Please consider repeat CBC as outpatient and consider further evaluation. -Code Status: DNR/DNI. - Safety Plan: Patient will be calling Officer ___ ___ cell) if there are any further safety issues. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Chlorthalidone 25 mg PO QAM 3. Levofloxacin 500 mg PO Q24H 4. Aspirin 81 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 7. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 2. Aspirin 81 mg PO DAILY 3. Atenolol 100 mg PO DAILY 4. Chlorthalidone 25 mg PO QAM 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= -Benign Paroxysmal Positional Vertigo -Post-traumatic stress disorder thought to be secondary to verbal abuse at home. Secondary Diagnosis =================== -Hypertension -Hypothyroidism -Prior CVA -Throat Cancer ___ -s/p Thyroidectomy -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 ___ ___ due to nausea and dizziness. You were seen by the Neurologists who recommended you undergo a CT scan of your head and neck. This did NOT show evidence of a new stroke. The dizziness you experienced seemed to be related to the movement of your head. This is known as "Benign positional vertigo." This usually resolves on its own. We also noticed that your symptoms of nausea/dizziness occurred when you were talking about your very stressful home situation. Stressors can make your symptoms worse. To help find a safe place for you to be discharged to, you were seen by Social Work. Their recommendations included a safety plan to contact the Police if you feel unsafe at home. Your friend, Officer ___ ___, can be reached at ___ cell), and was contacted to ensure you have more safety checks at home. Further, Elder Services were also contacted so that they can see you at home to ensure that it is a safe environment. Please follow up with your primary care physician and your specialists upon discharge from the hospital. It was a pleasure taking care of your during your hospitalization! We wish you all the best in the upcoming new year! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "H8110", "I69859", "F4310", "I10", "E039", "F329", "Z66", "R269", "Z7982", "Z8701" ]
Allergies: Influenza Virus Vaccines Chief Complaint: Headache, dizziness, nausea. Major Surgical or Invasive Procedure: There were no major surgical or invasive procedures during hospitalization. History of Present Illness: [MASKED] year who was sent in by [MASKED] on [MASKED] after experiencing headache and emesis. The headache was acute in onset however no headstrike or injuries were reported. She also developed bilateral lower extremity weakness requiring her to have to walk as she was unsteady on her feet. There was concern regarding her presentation as she experienced similar symptoms when she had a prior stroke. In the ED, initial vitals were: Pain 8, Temperature 96.8, HR 101, BP 155/93, RR 16, Pulse Ox 99% on RA. Urine/serum toxicology screen was negative. UA was negative. Chemistry panel was normal except for a BUN of 24. LFT's were normal except for an alk phos of 144. CBC was within normal limits. She underwent a CTA head and neck with preliminary reading showing "no flow limiting stenosis in the intracranial and cervical vessels. No evidence of aneurysm greater than 3 mm or dissection. Patent stent graft in the right common carotid artery. Calcified and non-calcified plaque at the left carotid bifurcation causing mild narrowing. Atherosclerotic calcification involving the left greater than right cervical vertebral arteries. Severe atherosclerotic disease of the aortic arch and descending aorta with both calcified and non-calcified plaque. Unchanged 8 mm right upper lobe pulmonary nodule, follow up per prior chest CT's." The patient was evaluated by neurology who suspected that the patient's current presentation was due to sub-acute spinal pathology coupled with ongoing medical illness and stress due to home situation. The patient was evaluated by [MASKED] in the ED who recommended [MASKED] visits or discharge to rehab. The patient was admitted to medicine for coordination of care and symptomatic management. On the floor, the patient reports improvement in her nausea and abdominal pain. She has some persistent left lower extremity weakness compared to right. She reports intermittent dizziness which she describes as the sensation that the room is spinning around her. She reports stress regarding her son and his issues with addiction, which she has dealt with for some time. She reported headache on presentation bi-temporal, which has improved. The patient does not remember the exact events when she was walking to her closet yesterday morning, but she did not experience any prodromal symptoms, nor changes in vision. Past Medical History: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy [MASKED] years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER [MASKED], FOLLOWED AT [MASKED] THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, [MASKED] BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT [MASKED] ? SEASONAL AFFECTIVE D/O [MASKED]: Admitted to [MASKED] for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: [MASKED] Family History: - Strong family history of malignancy. One brother deceased in his [MASKED] with liver malignancy, another in his [MASKED] with Lung Cancer. Mother deceased (reportedly at [MASKED]) in the setting of multiple medical problems plus a stroke. Her father died at [MASKED]. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 97.1, 138/70, 64, 18, 98% on RA General: alert, oriented, tearful when discussing son, otherwise not in acute distress HEENT: pale conjunctiva, JVP not visualized, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation, no oropharnygeal lesions visualized CV: RRR, nl S1 S2, no murmurs, rubs, gallops; no carotid bruit b/l Lungs: CTA b/l, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact (though patient refuses to extend tongue for testing of CN12), [MASKED] strength upper/lower extremities, grossly normal sensation, upgoing babinskin on left, downgoing on right, gait deferred, [MASKED] negative b/l, mild left lateral end-gaze nystagmus DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.2 [MASKED] 44-70 18 95-100%RA General: AOx3, lying in bed, appears comfortable, very pleasant HEENT: MMM, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation CV: RRR, normal S1 and S2 no m/r/g. Lungs: Clear to auscultation bilaterally. Abdomen: soft, nt, nd, no rebound or guarding. Ext: Warm, well perfused, no edema. Neuro: AOx3, EOMI, CNII-XII intact, strength/sensation grossly intact Pertinent Results: ADMISSION LABS ============== [MASKED] 01:45PM BLOOD WBC-4.6 RBC-5.18 Hgb-13.8 Hct-43.4 MCV-84 MCH-26.6 MCHC-31.8* RDW-16.2* RDWSD-49.3* Plt [MASKED] [MASKED] 01:45PM BLOOD Neuts-67.6 [MASKED] Monos-7.4 Eos-0.4* Baso-0.7 Im [MASKED] AbsNeut-3.10 AbsLymp-1.08* AbsMono-0.34 AbsEos-0.02* AbsBaso-0.03 [MASKED] 01:45PM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-140 K-3.8 Cl-101 HCO3-29 AnGap-14 [MASKED] 01:45PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.9 Mg-2.1 [MASKED] 01:45PM BLOOD ALT-31 AST-26 AlkPhos-144* TotBili-0.4 DISCHARGE LABS ============== [MASKED] 07:32AM BLOOD WBC-3.8* RBC-5.17 Hgb-13.7 Hct-42.5 MCV-82 MCH-26.5 MCHC-32.2 RDW-16.2* RDWSD-48.2* Plt [MASKED] [MASKED] 07:32AM BLOOD Glucose-95 UreaN-17 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-29 AnGap-13 [MASKED] 07:32AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0 SERUM TOXICOLOGY ================ [MASKED] 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE TOXICOLOGY ================ [MASKED] 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE STUDIES ============= [MASKED] 03:00PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ======= [MASKED]: CTA HEAD AND CTA NECK IMPRESSION: 1. Extensive periventricular and subcortical white matter hypodensities, relatively unchanged compared to the prior MRI allowing for the differences in technique. Please note that evaluation for an underlying acute infarct is limited given the extensive hypodensities. MRI of the brain can be performed for further evaluation as clinically indicated. 2. Vasogenic edema in the inferior right temporal lobe. The previously known enhancing lesion in the right temporal lobe is not well visualized on the CT scan. 3. Patent right internal and common carotid artery stent. 4. Atherosclerosis involving the left carotid bifurcation without any stenosis by NASCET criteria. 5. Atherosclerosis involving V2 segment of left vertebral artery causing focal areas of mild luminal narrowing. 6. Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. [MASKED]: PELVIS (AP ONLY) FINDINGS: No fracture or dislocation. Bilateral hip joint spaces are relatively well preserved with only minimal degenerative change. Pubic symphysis and SI joints are preserved. No radiopaque foreign body. Contrast is seen within the bladder. IMPRESSION: No fracture or dislocation. Brief Hospital Course: ASSESSMENT AND PLAN: [MASKED] with PMH of HTN, hypothyroidism, head and neck cancer s/p neck dissection x2 who presented with complaints of vertigo and leg weakness after fall with complex social situation concerning for abuse. # Vertigo secondary to BPPV versus Social Stressors/Anxiety: Ms. [MASKED] presented with nausea and dizziness. Based on description it appeared the vertigo appeared to be position in nature. Given her history of carotid stenosis, a CTA head and neck was obtained which did not show any evidence of new acute stroke. Neurology was consulted during hospitalization who did not believe symptoms could be explained by an acute stroke. Rather, they believed the symptoms were consistent with benign paroxysmal positional vertigo as neurologic exam was completely benign. During hospitalization, it was also noted that Ms. [MASKED] symptoms occurred when she was talking about her stressful home situation (a son at home who has a drug addiction and is verbally abusive to her). When talking to her son on the phone, Ms. [MASKED] would experience the dizziness and nausea. She also experienced these symptoms when she described her stressful home situation to the medical team. These symptoms would resolve after she had time to relax. Neurology did not believe any further work-up was necessary as an inpatient and recommended follow up with her Neurologist, Dr. [MASKED]. # Social Stressors/Verbal Abuse: Ms. [MASKED] described her stressful home situation with her son. She describes her son as addicted to crack. She also described numerous episodes of verbal abuse to her. She denied any physical abuse. Elder services had been involved in the past. Given this description, social work was heavily involved during this hospitalization and initial mandated reporting was done upon admission. She was hesitant to be discharged from the hospital until [MASKED] discharge plan was in place. Social work attempted to find other places for her to stay, however, patient elected to be discharged home. To facilitate a safe discharge plan, plans were made with [MASKED] Police if any abuse at home (plan would be contact Police at Precinct B2 with [MASKED] [MASKED] [MASKED] cell). These plans were also communicated with patient's daughter ([MASKED]) to instruct on when to call the police. Prior to her discharge, Elder Protective Services were called for wellness and home safety evaluations to occur at home. Ms. [MASKED] was able to voice back the safety plan that was developed and reported she felt comfortable with the safety plan. Attempts were made to locate safe housing prior to discharge,but patient denied further services. # Bacterial pneumonia: patient recently diagnosed with atypical pneumonia at PCP, started on course of levofloxacin [MASKED]. She completed her 10 day course of levofloxacin on [MASKED]. She was not experience cough or fever, and remained hemodynamically stable during hospitalization. # Hypertension: Continued atenolol, chlorthalidone, and aspirin during hospitalization. # Hypothyroidism: Continued levothyroxine during hospitalization. TRANSITIONAL ISSUES =================== - Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. Of note, this lesion has been documented on previous CT scans of the chest. - CTA Head and Neck: Marked atherosclerosis involving the aortic arch with penetrating atherosclerotic ulcer as seen on image 5:27. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. - Please continue to follow up with patient's safety situation at home - If further concerns for elder abuse, please contact Elder Services. - Patient was noted to have mild leukopenia on labs. Please consider repeat CBC as outpatient and consider further evaluation. -Code Status: DNR/DNI. - Safety Plan: Patient will be calling Officer [MASKED] [MASKED] cell) if there are any further safety issues. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Chlorthalidone 25 mg PO QAM 3. Levofloxacin 500 mg PO Q24H 4. Aspirin 81 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 7. Fish Oil (Omega 3) [MASKED] mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 2. Aspirin 81 mg PO DAILY 3. Atenolol 100 mg PO DAILY 4. Chlorthalidone 25 mg PO QAM 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Fish Oil (Omega 3) [MASKED] mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= -Benign Paroxysmal Positional Vertigo -Post-traumatic stress disorder thought to be secondary to verbal abuse at home. Secondary Diagnosis =================== -Hypertension -Hypothyroidism -Prior CVA -Throat Cancer [MASKED] -s/p Thyroidectomy -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 [MASKED] [MASKED] due to nausea and dizziness. You were seen by the Neurologists who recommended you undergo a CT scan of your head and neck. This did NOT show evidence of a new stroke. The dizziness you experienced seemed to be related to the movement of your head. This is known as "Benign positional vertigo." This usually resolves on its own. We also noticed that your symptoms of nausea/dizziness occurred when you were talking about your very stressful home situation. Stressors can make your symptoms worse. To help find a safe place for you to be discharged to, you were seen by Social Work. Their recommendations included a safety plan to contact the Police if you feel unsafe at home. Your friend, Officer [MASKED] [MASKED], can be reached at [MASKED] cell), and was contacted to ensure you have more safety checks at home. Further, Elder Services were also contacted so that they can see you at home to ensure that it is a safe environment. Please follow up with your primary care physician and your specialists upon discharge from the hospital. It was a pleasure taking care of your during your hospitalization! We wish you all the best in the upcoming new year! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I10", "E039", "F329", "Z66" ]
[ "H8110: Benign paroxysmal vertigo, unspecified ear", "I69859: Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side", "F4310: Post-traumatic stress disorder, unspecified", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z66: Do not resuscitate", "R269: Unspecified abnormalities of gait and mobility", "Z7982: Long term (current) use of aspirin", "Z8701: Personal history of pneumonia (recurrent)" ]
10,056,612
27,310,288
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / clopidogrel / lisinopril / chlorthalidone Attending: ___. Chief Complaint: Headache, HTN Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a pmh of CVA/TIA, HLD, HTN, laryngeal cancer, brain lesion (likely radiation necrosis), carotid stenosis s/p ___ stents, who presents for eval of headache and elevated BP. The patient endorses gradual onset right frontal headache with is throbbing in nature. She also endorses intermittent dizziness like the room is spinning, nausea, and decreased PO intake. She recently restarted her home atenolol with which she has been noncompliant for months due to insurance reasons, and only restarted 2 days ago. She says she has stopped Lisinopril due to cough. Has a history of prior similar headaches. No focal weakness. No chest pain or SOB. Denies ever getting HA with high BP's before. Checked her BP yesterday and it was 177/122 at ___. Called PCP office who instructed her to come in. In the ED, initial vitals were: 96.9, HR 54, 175/90, RR 16, 100% RA BP subsequently peaked at 220/110. Received 10mg IV Labetalol and down to 180-190's. Then received 100mg PO Labetalol and down to 159/68, later 112/45. Labs showed: Negative trop, normal UA, CBC, Chem 10, and Coags Imaging showed: CTA Head and Neck without intracranial hemorrhage, old infarcts and known temporal mass noted, new 1 mm aneurysm left vertebral artery, no flow-limiting stenosis Received Tylenol, 2L NS, in addition to the BP meds above Neuro was consulted, recommending BP control, MRI, and Medicine admission. On arrival to the floor, her HA was much improved, now "very little." Review of systems: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: Laryngeal cancer, ___ CVA/TIA Hypertension HLD Hypothyroidism after thyroid surgery for nodule ___ stenosis status post right carotid stents Cervical cancer, hysterectomy Tonsilectomy Appendectomy Right ankle fracture, pins placed Bilateral cataracts Social History: ___ Family History: She had two brothers, one died in his ___ with liver cancer and one died in his ___ with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION PHYSICAL EXAM: ================================ Vital Signs: 97.5, 151/82, HR 63, RR 20, 97% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple but TTP on right side (chronic), JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact. ___ strength in all 4 extremities. No pronator drift. DISCHARGE PHYSICAL EXAM: ================================= Vital Signs: 97.4 156/82 56 18 96 Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNIII-XII intact, though pt reports blurry vision. ___ strength in all 4 extremities. No pronator drift. Pertinent Results: ADMISSION LABS: ============================== ___ 07:40PM BLOOD WBC-4.5 RBC-4.87 Hgb-13.2 Hct-42.1 MCV-86 MCH-27.1 MCHC-31.4* RDW-15.1 RDWSD-47.7* Plt ___ ___ 07:40PM BLOOD Neuts-45.6 ___ Monos-8.2 Eos-2.4 Baso-0.4 Im ___ AbsNeut-2.05 AbsLymp-1.94 AbsMono-0.37 AbsEos-0.11 AbsBaso-0.02 ___ 07:40PM BLOOD ___ PTT-32.6 ___ ___ 07:40PM BLOOD Glucose-77 UreaN-20 Creat-0.8 Na-138 K-3.7 Cl-101 HCO3-27 AnGap-14 ___ 07:40PM BLOOD cTropnT-<0.01 ___ 07:40PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 ___ 08:55PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG MICRO: =============================== ___ URINE URINE CULTURE- **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. STUDIES: ============================== + CTA Head and Neck ___: 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. A right temporal lobe lesion identified on prior MRI is not appreciated. Adjacent white matter hypoattenuation is unchanged. 3. Lacunar infarcts involving the left basal ganglia and left pons are again noted. 4. Confluent periventricular and subcortical white matter hypoattenuation is unchanged. 5. There is a new 1 mm aneurysm involving the V2 segment of the left vertebral artery (series 5, image 175). 6. A right common carotid artery stent is widely patent. 7. There are dense atherosclerotic calcifications at the bifurcation of the left common carotid artery without evidence of flow-limiting stenosis. 8. The remaining major arteries of the neck are patent without evidence of flow-limiting stenosis, dissection, or aneurysm formation. + CXR ___: No acute cardiopulmonary abnormality. + MRI W/ AND W/O CONTRAST (___): Unchanged right temporal extra-axial lesion with unchanged surrounding edema. No acute infarcts mass effect or hydrocephalus. No new enhancing lesions. Superficial siderosis within the right temporal parietal sulcus better visualized on the current study. DISCHARGE LABS ___ 06:16AM BLOOD WBC-3.3* RBC-4.81 Hgb-13.0 Hct-41.4 MCV-86 MCH-27.0 MCHC-31.4* RDW-15.7* RDWSD-49.4* Plt ___ ___ 06:16AM BLOOD Glucose-73 UreaN-19 Creat-1.0 Na-143 K-4.2 Cl-105 HCO3-19* AnGap-23* ___ 06:16AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.___ y/o F with a history of CVA/TIA, HLD, HTN, laryngeal cancer, brain lesion (thought to be radiation necrosis), carotid stenosis s/p ___ stents who presents for fatigue, headache and elevated BP in setting of prolonged medication non-use secondary to insurance issues. Initial concern for hypertensive emergency (no other organ systems) though also concern for temporal brain lesion as etiology. She was seen by neuro-oncology who felt that brain lesion was not the culprit to explain her symptoms given stability on serial MRI. Blood pressure was controlled with new regimen of losartan and carvedilol with good response. TSH was elevated to 30 give recent medication non-use, levothyroxine was resumed. Notably, her headaches correlated with the times when she was quite hypertensive (SBP >185), and resolved with improved BP control, making hypertensive emergency a more likely unifying diagnosis. # Headache: #Hypertensive emergency: Presents with headache, poorly controlled BP, and recent med nonadherence due to insurance issues with presentation concerning for hypertensive emergency. SBP peaked in 200's, and DBP peaked in 120's at ___. CTA Head without any bleed or acute process, though does show old lacunar infarcts and left common carotid artery calcifications. Seen by Neuro in ED who felt this mostly represents hypertensive emergency, did not recommend Neuro admission, but did recommend MRI brain. UA, CXR, EKG, and labs reassuring. Notably, her headaches correlated with the times when she was quite hypertensive (SBP >185), and resolved with improved BP control, making hypertensive emergency a more likely unifying diagnosis. MRI brain stable from prior, and seen by neuro-oncology who felt that her symptoms were better explained by her HTN. She was started on carvedilol and amlodipine with good response. # Temporal Lobe Lesion: Thought to be probably radiation necrosis, rather than malignancy given the stability on serial imaging, though neurology consult with concern for neoplastic process. Case was discussed in neuro-oncology who felt given stable imaging, that her BP should be controlled and she could cont to follow up as an outpatient. # H/o CVA, TIA, carotid stenosis: No evidence of stroke of CVA on admission CTA or MRI. She was stared on aspirin. # Postsurgical Hypothyroidism: TSH elevated to 30 on admission though likely in the setting of not able to afford medications. Continued home Levothyroxine TRANSITIONAL: ============================ # CODE: Full # CONTACT/HCP: ___ / daughter / ___ alternative ___ (home) ___ (work) [ ] recheck TSH as outpatient in 6 weeks, titrate levothyroxine accordingly. [ ] Recommend ongoing titration of blood pressure medications. [ ] aspirin started while inpatient given history of CVAs. [ ] pt will have ophthalmology followup on discharge as ? blurry vision contributing to headaches [ ]Pt should have repeat serum chemistry evaluation given initiation of losartan close to hospital discharge Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. Atenolol 100 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Sertraline 25 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 3. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 4. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 6. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 7. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ======================= Hypertensive urgency Headache SECONDARY: ====================== Temporal lobe lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure meeting you and taking care of you. You were admitted to ___ for evaluation of fatigue and headache. You were found to have very high blood pressure, which improved with some some new medications. We also saw that your thyroid levels were really low and likely causing your fatigue. This should improve with resuming your home levothyroxine. We wish you the best, Your ___ team Followup Instructions: ___
[ "I161", "I6782", "F0390", "Z87891", "Z8673", "E785", "Z8521", "Z8541", "E890", "Y838", "F329", "Z9114" ]
Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / clopidogrel / lisinopril / chlorthalidone Chief Complaint: Headache, HTN Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with a pmh of CVA/TIA, HLD, HTN, laryngeal cancer, brain lesion (likely radiation necrosis), carotid stenosis s/p [MASKED] stents, who presents for eval of headache and elevated BP. The patient endorses gradual onset right frontal headache with is throbbing in nature. She also endorses intermittent dizziness like the room is spinning, nausea, and decreased PO intake. She recently restarted her home atenolol with which she has been noncompliant for months due to insurance reasons, and only restarted 2 days ago. She says she has stopped Lisinopril due to cough. Has a history of prior similar headaches. No focal weakness. No chest pain or SOB. Denies ever getting HA with high BP's before. Checked her BP yesterday and it was 177/122 at [MASKED]. Called PCP office who instructed her to come in. In the ED, initial vitals were: 96.9, HR 54, 175/90, RR 16, 100% RA BP subsequently peaked at 220/110. Received 10mg IV Labetalol and down to 180-190's. Then received 100mg PO Labetalol and down to 159/68, later 112/45. Labs showed: Negative trop, normal UA, CBC, Chem 10, and Coags Imaging showed: CTA Head and Neck without intracranial hemorrhage, old infarcts and known temporal mass noted, new 1 mm aneurysm left vertebral artery, no flow-limiting stenosis Received Tylenol, 2L NS, in addition to the BP meds above Neuro was consulted, recommending BP control, MRI, and Medicine admission. On arrival to the floor, her HA was much improved, now "very little." Review of systems: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: Laryngeal cancer, [MASKED] CVA/TIA Hypertension HLD Hypothyroidism after thyroid surgery for nodule [MASKED] stenosis status post right carotid stents Cervical cancer, hysterectomy Tonsilectomy Appendectomy Right ankle fracture, pins placed Bilateral cataracts Social History: [MASKED] Family History: She had two brothers, one died in his [MASKED] with liver cancer and one died in his [MASKED] with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION PHYSICAL EXAM: ================================ Vital Signs: 97.5, 151/82, HR 63, RR 20, 97% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple but TTP on right side (chronic), JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact. [MASKED] strength in all 4 extremities. No pronator drift. DISCHARGE PHYSICAL EXAM: ================================= Vital Signs: 97.4 156/82 56 18 96 Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNIII-XII intact, though pt reports blurry vision. [MASKED] strength in all 4 extremities. No pronator drift. Pertinent Results: ADMISSION LABS: ============================== [MASKED] 07:40PM BLOOD WBC-4.5 RBC-4.87 Hgb-13.2 Hct-42.1 MCV-86 MCH-27.1 MCHC-31.4* RDW-15.1 RDWSD-47.7* Plt [MASKED] [MASKED] 07:40PM BLOOD Neuts-45.6 [MASKED] Monos-8.2 Eos-2.4 Baso-0.4 Im [MASKED] AbsNeut-2.05 AbsLymp-1.94 AbsMono-0.37 AbsEos-0.11 AbsBaso-0.02 [MASKED] 07:40PM BLOOD [MASKED] PTT-32.6 [MASKED] [MASKED] 07:40PM BLOOD Glucose-77 UreaN-20 Creat-0.8 Na-138 K-3.7 Cl-101 HCO3-27 AnGap-14 [MASKED] 07:40PM BLOOD cTropnT-<0.01 [MASKED] 07:40PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 [MASKED] 08:55PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 08:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG MICRO: =============================== [MASKED] URINE URINE CULTURE- **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. STUDIES: ============================== + CTA Head and Neck [MASKED]: 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. A right temporal lobe lesion identified on prior MRI is not appreciated. Adjacent white matter hypoattenuation is unchanged. 3. Lacunar infarcts involving the left basal ganglia and left pons are again noted. 4. Confluent periventricular and subcortical white matter hypoattenuation is unchanged. 5. There is a new 1 mm aneurysm involving the V2 segment of the left vertebral artery (series 5, image 175). 6. A right common carotid artery stent is widely patent. 7. There are dense atherosclerotic calcifications at the bifurcation of the left common carotid artery without evidence of flow-limiting stenosis. 8. The remaining major arteries of the neck are patent without evidence of flow-limiting stenosis, dissection, or aneurysm formation. + CXR [MASKED]: No acute cardiopulmonary abnormality. + MRI W/ AND W/O CONTRAST ([MASKED]): Unchanged right temporal extra-axial lesion with unchanged surrounding edema. No acute infarcts mass effect or hydrocephalus. No new enhancing lesions. Superficial siderosis within the right temporal parietal sulcus better visualized on the current study. DISCHARGE LABS [MASKED] 06:16AM BLOOD WBC-3.3* RBC-4.81 Hgb-13.0 Hct-41.4 MCV-86 MCH-27.0 MCHC-31.4* RDW-15.7* RDWSD-49.4* Plt [MASKED] [MASKED] 06:16AM BLOOD Glucose-73 UreaN-19 Creat-1.0 Na-143 K-4.2 Cl-105 HCO3-19* AnGap-23* [MASKED] 06:16AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.[MASKED] y/o F with a history of CVA/TIA, HLD, HTN, laryngeal cancer, brain lesion (thought to be radiation necrosis), carotid stenosis s/p [MASKED] stents who presents for fatigue, headache and elevated BP in setting of prolonged medication non-use secondary to insurance issues. Initial concern for hypertensive emergency (no other organ systems) though also concern for temporal brain lesion as etiology. She was seen by neuro-oncology who felt that brain lesion was not the culprit to explain her symptoms given stability on serial MRI. Blood pressure was controlled with new regimen of losartan and carvedilol with good response. TSH was elevated to 30 give recent medication non-use, levothyroxine was resumed. Notably, her headaches correlated with the times when she was quite hypertensive (SBP >185), and resolved with improved BP control, making hypertensive emergency a more likely unifying diagnosis. # Headache: #Hypertensive emergency: Presents with headache, poorly controlled BP, and recent med nonadherence due to insurance issues with presentation concerning for hypertensive emergency. SBP peaked in 200's, and DBP peaked in 120's at [MASKED]. CTA Head without any bleed or acute process, though does show old lacunar infarcts and left common carotid artery calcifications. Seen by Neuro in ED who felt this mostly represents hypertensive emergency, did not recommend Neuro admission, but did recommend MRI brain. UA, CXR, EKG, and labs reassuring. Notably, her headaches correlated with the times when she was quite hypertensive (SBP >185), and resolved with improved BP control, making hypertensive emergency a more likely unifying diagnosis. MRI brain stable from prior, and seen by neuro-oncology who felt that her symptoms were better explained by her HTN. She was started on carvedilol and amlodipine with good response. # Temporal Lobe Lesion: Thought to be probably radiation necrosis, rather than malignancy given the stability on serial imaging, though neurology consult with concern for neoplastic process. Case was discussed in neuro-oncology who felt given stable imaging, that her BP should be controlled and she could cont to follow up as an outpatient. # H/o CVA, TIA, carotid stenosis: No evidence of stroke of CVA on admission CTA or MRI. She was stared on aspirin. # Postsurgical Hypothyroidism: TSH elevated to 30 on admission though likely in the setting of not able to afford medications. Continued home Levothyroxine TRANSITIONAL: ============================ # CODE: Full # CONTACT/HCP: [MASKED] / daughter / [MASKED] alternative [MASKED] (home) [MASKED] (work) [ ] recheck TSH as outpatient in 6 weeks, titrate levothyroxine accordingly. [ ] Recommend ongoing titration of blood pressure medications. [ ] aspirin started while inpatient given history of CVAs. [ ] pt will have ophthalmology followup on discharge as ? blurry vision contributing to headaches [ ]Pt should have repeat serum chemistry evaluation given initiation of losartan close to hospital discharge Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN sob 2. Atenolol 100 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Sertraline 25 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 3. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 4. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 6. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN sob 7. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ======================= Hypertensive urgency Headache SECONDARY: ====================== Temporal lobe lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure meeting you and taking care of you. You were admitted to [MASKED] for evaluation of fatigue and headache. You were found to have very high blood pressure, which improved with some some new medications. We also saw that your thyroid levels were really low and likely causing your fatigue. This should improve with resuming your home levothyroxine. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "Z87891", "Z8673", "E785", "F329" ]
[ "I161: Hypertensive emergency", "I6782: Cerebral ischemia", "F0390: Unspecified dementia without behavioral disturbance", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "Z8521: Personal history of malignant neoplasm of larynx", "Z8541: Personal history of malignant neoplasm of cervix uteri", "E890: Postprocedural hypothyroidism", "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", "F329: Major depressive disorder, single episode, unspecified", "Z9114: Patient's other noncompliance with medication regimen" ]
10,057,009
28,491,028
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH of HTN, HLD who presents with cough and SOB. This has been developing over several weeks. She denies fever, chills. Found to have an elevated BNP to >15000 with EKG showing atrial fibrillation, LAD, mildly prolonged QRS c/w LAFB, 1mm STE in III with STD in I - unchanged from prior; TWI in V1-V5, new from prior, w/ new T wave flattening in II, V6. Trops x 3 negative. Also found to have hyponatremia to 129. Started on IV heparin for ? ACS vs. afib, transitioned to apixiban. ECHO pending. Getting IV diuresis Past Medical History: 1. Hypertension. 2. Osteoarthritis. 3. Hypercholesterolemia. Social History: ___ Family History: Father had prostate surgery at ___ years and passed away at ___. Mother died at a younger age with MI, a brother had myocardial infarction as well and he was a smoker. No history of dementia in the family. Physical Exam: ADMISSION EXAM: Physical Exam: Vitals- T:97.3 BP:128 87 HR:94 RR:16 O2:94 RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM: Vitals- T:98.2 BP:107-126/65-84 HR:80's RR:16 O2:95 RA General- Alert, oriented, sitting up in bed and eating breakfast. No acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, 1+ edema in lower extremities bilaterally. Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 07:39PM ___ PO2-39* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 ___ 07:39PM LACTATE-2.2* ___ 07:30PM ALT(SGPT)-47* AST(SGOT)-65* ALK PHOS-94 TOT BILI-1.1 ___ 07:30PM ___ ___ 07:30PM CALCIUM-9.4 MAGNESIUM-2.0 ___ 07:30PM ___ ___ 05:25PM GLUCOSE-106* UREA N-22* CREAT-0.9 SODIUM-129* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-17* ANION GAP-23* ___ 05:25PM estGFR-Using this ___ 05:25PM cTropnT-<0.01 ___ 05:25PM CALCIUM-9.4 MAGNESIUM-2.1 ___ 05:25PM WBC-9.7 RBC-4.90 HGB-13.8 HCT-42.6 MCV-87# MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-44.0 ___ 05:25PM NEUTS-69.7 ___ MONOS-9.1 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-6.78* AbsLymp-1.99 AbsMono-0.88* AbsEos-0.01* AbsBaso-0.02 ___ 05:25PM PLT COUNT-210 DISCHARGE LABS: ___ 06:00AM BLOOD WBC-5.6 RBC-4.40 Hgb-12.7 Hct-39.0 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.7 RDWSD-45.8 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 03:24PM BLOOD Glucose-116* UreaN-25* Creat-1.1 Na-136 K-5.1 Cl-99 HCO3-24 AnGap-18 ___ 03:24PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0 Imaging: IMPRESSION: Limited exam without definite acute cardiopulmonary process. Specifically, no visualized focal consolidation concerning for pneumonia. Brief Hospital Course: Ms. ___ is an ___ with PMH of HTN, HLD who presented to the ___ ED with cough and DOE for 2 weeks. She was found to have hyponatremia, an elevated AG, changes on ECG concerning for ischemia, new onset atrial fibrillation and elevated BNP concerning for CHF. She was discharged on ___. # Dyspnea/cough: most likely multifactorial, related to new AF, possibly cardiac ischemia and some element of volume overload given elevated BNP. Of note pt endorsed a chronic dry cough for years which was, per notation by cardiology likely related to lisinopril. This episode was more acute. However, we changed to losartan to simplify future clinical presentations. CXR did not show evidence of pulmonary edema or infection, though exam was limited given patient's habitus w/kyphosis. Possibly new diagnosis of CHF, perhaps provoked by cardiac ischemia (see below) vs. tachycardia induced cardiomyopathy in the setting of AF and h/o of intermittent palpitations with PACs. The latter seems less likely as patient's HR has been controlled throughout admission and she is on metoprolol at baseline. Lactate was slightly elevated to 2.2 on admission, at 1.4 on ___. Acutely decompensated CHF was less likely as she was warm on exam. Beta blockers were continued. Prior cardiology note described cough as possibly being ACEI-induced. She was switched from lisinopril to losartan given concern for ACEI-induced cough. She was given IV Lasix 10 mg boluses and had good urine output. She will need a TTE as an outpatient and cardiology follow up. Patient stated if she were to have evidence of ischemia on her echo she would not want a stent, however with son in the room he stated she did not fully understand the implications. They had many questions which will need to be concretly and clearly stated at follow up visits. -started on 10mg furosemide -pt with follow up ___ for weight, lytes. # Atrial Fibrillation: patient with AF on ECG at presentation and was never noted on prior ECGs. Patient does have history of "skipped beats" for which she was evaluated by cardiology and treated with metoprolol. It is possible that this may have represented AF, not captured on ECG. Her current presentation may be AF-provoked in the setting of CHF vs. cardiac ischemia or vice versa. Patient with CHADSVASC 4 given age, HTN and female sex. Heparin was initiated on admission for anticoagulation. She was switched to apixaban 2.5 mg BID and continued on home metoprolol. # TWI on ECG: patient had TWI on ECG at admission, may be rate related changes in the setting of new AF vs. related to cardiac ischemia. She was without symptoms of chest pain, but did have DOE. Trops x 3 were negative, MB 7. In discussion regarding further work-up, patient indicated that she would not like to have any invasive procedure should she be found to have CAD. She was continued on ___, statin. Will follow up with her cardiologist as an outpatient. # Hyponatremia: her hyponatremia on admission was likely hypervolemic in the setting of elevated BNP and possible volume overload. She had a prior history of hyponatremia which was attributed to poor PO intake and improved with IVF. Na was 129 on admission and improved to 137 on ___ with diuretics. # Transaminitis: Elevated AST and ALT on admission, possibly due to congestion in the setting of possible CHF. Transaminitis resolved on ___. # Elevated AG: Patient with AG 18 on admission that resolved on ___. Had normal pH on VBG. Lactate was slightly elevated. Delta/Delta 1 suggestive of pure AG process. Evaluated with serum ___ to r/o salicylate toxicity in the ED, which was negative. Patient with no history of other exposure of ingestion. Other possible etiology is ketonemia in the setting of decreased PO intake. This resolved on admission. # Hypertension: H/o HTN. Swtiched from lisinopril 10 mg to losartan 50 mg given concern for ACE-induced cough. # HLD: Continued on statin. Transitional Issues: - Will need outpatient ECHO for ? diagnosis of CHF - Discussed with patient and son the need for assistance with ___ services, however, declined at this time over what he described were privacy issues of the patient and would need to discuss slowly over time. We would like to be offered this option at a later time. - Provided with a script for outpatient ___ - Will need outpatient cardiology evaluation and possible stress test # CODE STATUS: Full Name of health care proxy: ___ Relationship: sons Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Simvastatin 5 mg PO HS 4. Vitamin D 800 UNIT PO DAILY 5. ammonium lactate 12 % topical DAILY:PRN 6. Ketoconazole 2% 1 Appl TP BID 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NS DAILY RX *fluticasone 50 mcg/actuation 1 spray nasal daily each nare Disp #*1 Spray Refills:*0 3. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 4. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. ammonium lactate 12 % topical DAILY:PRN 6. Aspirin 81 mg PO DAILY 7. Ketoconazole 2% 1 Appl TP BID 8. Metoprolol Succinate XL 75 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation 10. Simvastatin 5 mg PO HS 11. Vitamin D 800 UNIT PO DAILY 12.Outpatient Physical Therapy ___ with PMH of HTN, HLD who presents with cough and SOB, new dx of afib Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation Hypervolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with trouble breathing and a cough. We found you to have extra fluid in your body so we gave you an intravenous form of the water pill to help you pee it out. We thought your cough might be related to one of your medications, called lisinopril, so we switched it to another blood pressure medication, losartan. You were also found to have an abnormal heart rhythm called atrial fibrillation. We started you on a medication called Eliquis (apixaban)to thin out your blood and decreases your risk of having a stroke. It was a pleasure caring for you. Wishing you the best, Your ___ Team Followup Instructions: ___
[ "I4891", "I5021", "E871", "M4150", "I110", "R9431", "R740", "R7989", "Z7902", "E7800", "Z23", "E119", "M810" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMH of HTN, HLD who presents with cough and SOB. This has been developing over several weeks. She denies fever, chills. Found to have an elevated BNP to >15000 with EKG showing atrial fibrillation, LAD, mildly prolonged QRS c/w LAFB, 1mm STE in III with STD in I - unchanged from prior; TWI in V1-V5, new from prior, w/ new T wave flattening in II, V6. Trops x 3 negative. Also found to have hyponatremia to 129. Started on IV heparin for ? ACS vs. afib, transitioned to apixiban. ECHO pending. Getting IV diuresis Past Medical History: 1. Hypertension. 2. Osteoarthritis. 3. Hypercholesterolemia. Social History: [MASKED] Family History: Father had prostate surgery at [MASKED] years and passed away at [MASKED]. Mother died at a younger age with MI, a brother had myocardial infarction as well and he was a smoker. No history of dementia in the family. Physical Exam: ADMISSION EXAM: Physical Exam: Vitals- T:97.3 BP:128 87 HR:94 RR:16 O2:94 RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM: Vitals- T:98.2 BP:107-126/65-84 HR:80's RR:16 O2:95 RA General- Alert, oriented, sitting up in bed and eating breakfast. No acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, 1+ edema in lower extremities bilaterally. Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [MASKED] 07:39PM [MASKED] PO2-39* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 [MASKED] 07:39PM LACTATE-2.2* [MASKED] 07:30PM ALT(SGPT)-47* AST(SGOT)-65* ALK PHOS-94 TOT BILI-1.1 [MASKED] 07:30PM [MASKED] [MASKED] 07:30PM CALCIUM-9.4 MAGNESIUM-2.0 [MASKED] 07:30PM [MASKED] [MASKED] 05:25PM GLUCOSE-106* UREA N-22* CREAT-0.9 SODIUM-129* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-17* ANION GAP-23* [MASKED] 05:25PM estGFR-Using this [MASKED] 05:25PM cTropnT-<0.01 [MASKED] 05:25PM CALCIUM-9.4 MAGNESIUM-2.1 [MASKED] 05:25PM WBC-9.7 RBC-4.90 HGB-13.8 HCT-42.6 MCV-87# MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-44.0 [MASKED] 05:25PM NEUTS-69.7 [MASKED] MONOS-9.1 EOS-0.1* BASOS-0.2 IM [MASKED] AbsNeut-6.78* AbsLymp-1.99 AbsMono-0.88* AbsEos-0.01* AbsBaso-0.02 [MASKED] 05:25PM PLT COUNT-210 DISCHARGE LABS: [MASKED] 06:00AM BLOOD WBC-5.6 RBC-4.40 Hgb-12.7 Hct-39.0 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.7 RDWSD-45.8 Plt [MASKED] [MASKED] 06:00AM BLOOD Plt [MASKED] [MASKED] 03:24PM BLOOD Glucose-116* UreaN-25* Creat-1.1 Na-136 K-5.1 Cl-99 HCO3-24 AnGap-18 [MASKED] 03:24PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0 Imaging: IMPRESSION: Limited exam without definite acute cardiopulmonary process. Specifically, no visualized focal consolidation concerning for pneumonia. Brief Hospital Course: Ms. [MASKED] is an [MASKED] with PMH of HTN, HLD who presented to the [MASKED] ED with cough and DOE for 2 weeks. She was found to have hyponatremia, an elevated AG, changes on ECG concerning for ischemia, new onset atrial fibrillation and elevated BNP concerning for CHF. She was discharged on [MASKED]. # Dyspnea/cough: most likely multifactorial, related to new AF, possibly cardiac ischemia and some element of volume overload given elevated BNP. Of note pt endorsed a chronic dry cough for years which was, per notation by cardiology likely related to lisinopril. This episode was more acute. However, we changed to losartan to simplify future clinical presentations. CXR did not show evidence of pulmonary edema or infection, though exam was limited given patient's habitus w/kyphosis. Possibly new diagnosis of CHF, perhaps provoked by cardiac ischemia (see below) vs. tachycardia induced cardiomyopathy in the setting of AF and h/o of intermittent palpitations with PACs. The latter seems less likely as patient's HR has been controlled throughout admission and she is on metoprolol at baseline. Lactate was slightly elevated to 2.2 on admission, at 1.4 on [MASKED]. Acutely decompensated CHF was less likely as she was warm on exam. Beta blockers were continued. Prior cardiology note described cough as possibly being ACEI-induced. She was switched from lisinopril to losartan given concern for ACEI-induced cough. She was given IV Lasix 10 mg boluses and had good urine output. She will need a TTE as an outpatient and cardiology follow up. Patient stated if she were to have evidence of ischemia on her echo she would not want a stent, however with son in the room he stated she did not fully understand the implications. They had many questions which will need to be concretly and clearly stated at follow up visits. -started on 10mg furosemide -pt with follow up [MASKED] for weight, lytes. # Atrial Fibrillation: patient with AF on ECG at presentation and was never noted on prior ECGs. Patient does have history of "skipped beats" for which she was evaluated by cardiology and treated with metoprolol. It is possible that this may have represented AF, not captured on ECG. Her current presentation may be AF-provoked in the setting of CHF vs. cardiac ischemia or vice versa. Patient with CHADSVASC 4 given age, HTN and female sex. Heparin was initiated on admission for anticoagulation. She was switched to apixaban 2.5 mg BID and continued on home metoprolol. # TWI on ECG: patient had TWI on ECG at admission, may be rate related changes in the setting of new AF vs. related to cardiac ischemia. She was without symptoms of chest pain, but did have DOE. Trops x 3 were negative, MB 7. In discussion regarding further work-up, patient indicated that she would not like to have any invasive procedure should she be found to have CAD. She was continued on [MASKED], statin. Will follow up with her cardiologist as an outpatient. # Hyponatremia: her hyponatremia on admission was likely hypervolemic in the setting of elevated BNP and possible volume overload. She had a prior history of hyponatremia which was attributed to poor PO intake and improved with IVF. Na was 129 on admission and improved to 137 on [MASKED] with diuretics. # Transaminitis: Elevated AST and ALT on admission, possibly due to congestion in the setting of possible CHF. Transaminitis resolved on [MASKED]. # Elevated AG: Patient with AG 18 on admission that resolved on [MASKED]. Had normal pH on VBG. Lactate was slightly elevated. Delta/Delta 1 suggestive of pure AG process. Evaluated with serum [MASKED] to r/o salicylate toxicity in the ED, which was negative. Patient with no history of other exposure of ingestion. Other possible etiology is ketonemia in the setting of decreased PO intake. This resolved on admission. # Hypertension: H/o HTN. Swtiched from lisinopril 10 mg to losartan 50 mg given concern for ACE-induced cough. # HLD: Continued on statin. Transitional Issues: - Will need outpatient ECHO for ? diagnosis of CHF - Discussed with patient and son the need for assistance with [MASKED] services, however, declined at this time over what he described were privacy issues of the patient and would need to discuss slowly over time. We would like to be offered this option at a later time. - Provided with a script for outpatient [MASKED] - Will need outpatient cardiology evaluation and possible stress test # CODE STATUS: Full Name of health care proxy: [MASKED] Relationship: sons Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Simvastatin 5 mg PO HS 4. Vitamin D 800 UNIT PO DAILY 5. ammonium lactate 12 % topical DAILY:PRN 6. Ketoconazole 2% 1 Appl TP BID 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NS DAILY RX *fluticasone 50 mcg/actuation 1 spray nasal daily each nare Disp #*1 Spray Refills:*0 3. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 4. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. ammonium lactate 12 % topical DAILY:PRN 6. Aspirin 81 mg PO DAILY 7. Ketoconazole 2% 1 Appl TP BID 8. Metoprolol Succinate XL 75 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation 10. Simvastatin 5 mg PO HS 11. Vitamin D 800 UNIT PO DAILY 12.Outpatient Physical Therapy [MASKED] with PMH of HTN, HLD who presents with cough and SOB, new dx of afib Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation Hypervolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with trouble breathing and a cough. We found you to have extra fluid in your body so we gave you an intravenous form of the water pill to help you pee it out. We thought your cough might be related to one of your medications, called lisinopril, so we switched it to another blood pressure medication, losartan. You were also found to have an abnormal heart rhythm called atrial fibrillation. We started you on a medication called Eliquis (apixaban)to thin out your blood and decreases your risk of having a stroke. It was a pleasure caring for you. Wishing you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I4891", "E871", "I110", "Z7902", "E119" ]
[ "I4891: Unspecified atrial fibrillation", "I5021: Acute systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "M4150: Other secondary scoliosis, site unspecified", "I110: Hypertensive heart disease with heart failure", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R7989: Other specified abnormal findings of blood chemistry", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E7800: Pure hypercholesterolemia, unspecified", "Z23: Encounter for immunization", "E119: Type 2 diabetes mellitus without complications", "M810: Age-related osteoporosis without current pathological fracture" ]
10,057,070
20,793,141
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Apnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of sleep apnea, alcohol abuse, heart failure who presents from his ___ facility for evaluation of episode of apnea. The facility reported that he has been more sleepy than usual over the past 24 hours since starting Librium. This evening he was trying to sleep (without CPAP), when he was noted to have an episode of apnea lasting for about ___ seconds. It was difficult to arouse him at that time period prompting his staff to transfer here to the hospital for further evaluation. The patient reportedly noted intermittent episodes of substernal, non-radiating chest pain over the past few days without clear exertional pattern. He did also reportedly acknowledge his shortness of breath for the past week. In the ED, initial vitals: 97.6 92 148/78 16 100% Non-Rebreather Labs were significant for: normal WBC 5.7, proBNP 447, Trop <0.01, K 5.7, VBG 7.3/___/115/34 Imaging was significant for: CXR with low lung volumes, bilateral pulmonary edema EKG: sinus rhythm, normal axis, normal intervals, T wave flattening in lateral precordial leads. He was placed on BiPAP in the ED. Due waxing/waning mental status, he received flumazenil x2 with transient improvement in his mental status. He was evaluated by anesthesia in the ED who advised that he would be a difficult intubation. On arrival to the MICU, the patient is somnolent & MICU team unable to evaluate ROS. Review of systems: (+) Per HPI; Unable to evaluate ROS Past Medical History: Sleep apnea on CPAP ?CHF EtOH abuse ?CAD Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T:Afebrile BP:115/57 P:77 R:18 O2: 96% on BiPAP at ___ GENERAL: Somnolent, arousable to very loud voice/light sternal rub, on BiPAP HEENT: Pupils pinpoint, minimally reactive, but equal. Sclera anicteric, MMM, oropharynx clear NECK: Thick, unable to assess for JVD LUNGS: Not tachypneic, tolerating BiPAP. Clear to auscultation bilaterally anteriorly. CV: Distant heart sounds. Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. ACCESS: PIVs DISCHARGE PHYSICAL EXAM PHYSICAL EXAM: Vitals: T 98.1 BP 112/66 HR 76 RR 18 O2 98% on CPAP I/O: 1140/1850 // ___ General: Latino gentleman sitting up in a chair this morning. In NAD. Not diaphoretic this AM. HEENT: Sclerae injected, but with no discharge. Lungs: Distant lung sounds. Clear to auscultation bilaterally. CV: Distant heart sounds. RRR no murmurs, rubs, gallops Abdomen: Soft, non tender, nondistended. Ext: +1 pitting edema to the knee bilaterally. Otherwise warm and well perfused, +1 posterior tibialis pulses bilaterally. Neuro: Moves all four extremities purposefully. Pertinent Results: ============== ADMISSION LABS ============== ___ 09:35PM BLOOD WBC-5.7 RBC-4.95 Hgb-14.0 Hct-44.5 MCV-90 MCH-28.3 MCHC-31.5* RDW-13.1 RDWSD-43.0 Plt ___ ___ 09:35PM BLOOD ___ PTT-26.0 ___ ___ 09:35PM BLOOD Glucose-326* UreaN-17 Creat-0.9 Na-135 K-5.7* Cl-94* HCO3-31 AnGap-16 ___ 09:35PM BLOOD ALT-22 AST-44* AlkPhos-49 TotBili-0.2 ___ 09:35PM BLOOD proBNP-447* ___ 02:42AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.0 ___ 09:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG ___ 10:01PM BLOOD ___ pO2-115* pCO2-67* pH-7.30* calTCO2-34* Base XS-3 Comment-GREEN TOP ___ 10:01PM BLOOD O2 Sat-96 ___ 06:46AM BLOOD Lactate-1.2 ___ 02:42AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:42AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 02:42AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 ___ 02:42AM URINE CastHy-2* ___ 02:42AM URINE Mucous-RARE ================= PERTINENT IMAGING ================= ------------------ CXR (___): Evaluation is limited by low lung volumes and large body habitus. The lungs are grossly clear. Hila appear slightly congested. The heart and mediastinal contours appear mildly prominent likely due to supine portable technique. No supine evidence for large effusion or pneumothorax. Bony structures are intact. ------------------ ============== DISCHARGE LABS ============== ___ 07:25AM BLOOD WBC-6.2 RBC-4.96 Hgb-14.6 Hct-45.5 MCV-92 MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-43.9 Plt ___ ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-31 AnGap-13 ___ 07:25AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.___ with OSA, CHF, EtOH abuse who presents with an episode of apnea and hypercarbic respiratory failure in the context of recent attempt to detox from ETOH at ___. was witnessed to be altered and have a ___ second episode of apnea while at ___. Had been starting Librium there. In ED given flumazenil x2, noted to be significantly altered and minimally responsive. Briefly admitted to the MICU where he was put on BiPAP and put on phenobarbital pathway. Respiratory failure resolved with BiPAP + O2 at night to avoid desaturations. He was medically detoxed from alcohol on the phenobarb taper. He was A&O x3 at discharge. MICU COURSE ----------- #Hypercarbic respiratory failure: Most likely multifactorial, depressed respiratory drive in the setting of benzodiazepine/potential other drug overdose, pulmonary edema secondary to possible heart failure, sleep apnea in the setting of no CPAP, and possible obstructive lung disease. Patient was treated with 80 mg IV Lasix with appropriate urine output. He was intermittently put on BiPAP with close monitoring of his respiratory status. #Acute encephalopathy: Most likely multifactorial due to hypercarbia, benzodiazepine/other toxic ingestion. Urine and serum tox screens were positive for benzodiazepines on admission, in the setting of Librium intake at his ___ facility. #EtOH abuse: Treated with phenobarbital load and taper, with high dose IV thiamine, folate, and multivitamin. #Diabetes: Novolog was restarted once his mental status improved and he was tolerating po intake. ============= ACTIVE ISSUES ============= # HYPERCARBIC RESPIRATORY FAILURE: Improved with nightly BiPAP + O2, 3 rounds of 60mg IV Lasix. Was saturating well on room air and mentating well prior to discharge. - Home diuretics resumed - BiPAP at night with O2 # ETOH WITHDRAWAL: Completed phenobarbital taper on ___. Has been medically detoxified from alcohol. - Prescribed thiamine, folate, MVI. ===================== CHRONIC/STABLE ISSUES ===================== # ACUTE ENCEPHALOPATHY: Resolved with treatment of hypercarbic respiratory failure as above. - Treat respiratory failure as above - F/u blood cultures # CHEST PAIN: Brief episode of substernal CP. EKG without signs of active ischemia, troponin negative x2. # CONGESTIVE HEART FAILURE: Diuresed with Lasix 60mg IV x3 here, then euvolemic on home Lasix. - Home Lasix - Discharge weight: 112.6kg # DIABETES: - Home 70/30 insulin # h/o COPD: - Home fluticasone - Home albuterol # MEDICATION RECONCILIATION/?h/o CAD: - Continue home atorvastatin and baby ASA =================== TRANSITIONAL ISSUES =================== # CODE: Full # CONTACT: Sister ___ ___ [ ] MEDICATION CHANGES: - Added thiamine, MVI, folate PO [ ] ETOH WITHDRAWAL: - Medically detoxed from alcohol on phenobarb taper as of ___. - Continue to encourage efforts at abstinence. [ ] OBSTRUCTIVE SLEEP APNEA: - Pt with nighttime apnea and desaturations. Requires BiPAP with O2 to avoid nighttime desaturations and apnea. [ ] CONGESTIVE HEART FAILURE: - Discharge weight: 112.6kg >30 minutes coordinating discharge from the hospital Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 40 mg PO QHS 2. Furosemide 80 mg PO QAM 3. Lisinopril 40 mg PO DAILY 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Atorvastatin 80 mg PO QPM 6. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puff Q4H:PRN wheeze or SOB 7. Clotrimazole Cream 1 Appl TP BID 8. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 9. Aspirin 81 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Furosemide 40 mg PO QHS 7. Furosemide 80 mg PO QAM 8. Lisinopril 40 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puff Q4H:PRN wheeze or SOB Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Alcohol withdrawal SECONDARY: Obstructive sleep apnea Congestive heart failure exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were seen in our hospital because people noticed you stopped breathing while at your alcohol detox ___. On arrival to the hospital, you were very sleepy. We gave you medications to reverse things that could be possibly contributing to your sleepiness, and then put you on a drug called "phenobarbital" to help detox you from alcohol. We also gave you a BiPAP machine and oxygen to use at night. At this point, you have been detoxed here and you are medically stable for Clinical Support Services. You have a history of obstructive sleep apnea, and need to be able to bring your CPAP machine and oxygen to whatever facility you enter. Please present this sheet, or an attached letter, to staff at your facility to let them know this. You have been started on new vitamins, "folate" and "thiamine." Please take these every day to help with your nutrition. Please continue to use your eyedrops as prescribed for one week. If you experience worsening vision changes, or your eye itching/discharge is not improved by that time, please call your primary care physician for further followup. We wish you the best, Your ___ Care Team Followup Instructions: ___
[ "J9622", "G9340", "I501", "E1165", "D751", "F10239", "Z720", "T424X5A", "Y929", "G4733", "I2510", "Z794", "Z23", "R0789" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Apnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of sleep apnea, alcohol abuse, heart failure who presents from his [MASKED] facility for evaluation of episode of apnea. The facility reported that he has been more sleepy than usual over the past 24 hours since starting Librium. This evening he was trying to sleep (without CPAP), when he was noted to have an episode of apnea lasting for about [MASKED] seconds. It was difficult to arouse him at that time period prompting his staff to transfer here to the hospital for further evaluation. The patient reportedly noted intermittent episodes of substernal, non-radiating chest pain over the past few days without clear exertional pattern. He did also reportedly acknowledge his shortness of breath for the past week. In the ED, initial vitals: 97.6 92 148/78 16 100% Non-Rebreather Labs were significant for: normal WBC 5.7, proBNP 447, Trop <0.01, K 5.7, VBG 7.3/[MASKED]/115/34 Imaging was significant for: CXR with low lung volumes, bilateral pulmonary edema EKG: sinus rhythm, normal axis, normal intervals, T wave flattening in lateral precordial leads. He was placed on BiPAP in the ED. Due waxing/waning mental status, he received flumazenil x2 with transient improvement in his mental status. He was evaluated by anesthesia in the ED who advised that he would be a difficult intubation. On arrival to the MICU, the patient is somnolent & MICU team unable to evaluate ROS. Review of systems: (+) Per HPI; Unable to evaluate ROS Past Medical History: Sleep apnea on CPAP ?CHF EtOH abuse ?CAD Social History: [MASKED] Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T:Afebrile BP:115/57 P:77 R:18 O2: 96% on BiPAP at [MASKED] GENERAL: Somnolent, arousable to very loud voice/light sternal rub, on BiPAP HEENT: Pupils pinpoint, minimally reactive, but equal. Sclera anicteric, MMM, oropharynx clear NECK: Thick, unable to assess for JVD LUNGS: Not tachypneic, tolerating BiPAP. Clear to auscultation bilaterally anteriorly. CV: Distant heart sounds. Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. ACCESS: PIVs DISCHARGE PHYSICAL EXAM PHYSICAL EXAM: Vitals: T 98.1 BP 112/66 HR 76 RR 18 O2 98% on CPAP I/O: 1140/1850 // [MASKED] General: Latino gentleman sitting up in a chair this morning. In NAD. Not diaphoretic this AM. HEENT: Sclerae injected, but with no discharge. Lungs: Distant lung sounds. Clear to auscultation bilaterally. CV: Distant heart sounds. RRR no murmurs, rubs, gallops Abdomen: Soft, non tender, nondistended. Ext: +1 pitting edema to the knee bilaterally. Otherwise warm and well perfused, +1 posterior tibialis pulses bilaterally. Neuro: Moves all four extremities purposefully. Pertinent Results: ============== ADMISSION LABS ============== [MASKED] 09:35PM BLOOD WBC-5.7 RBC-4.95 Hgb-14.0 Hct-44.5 MCV-90 MCH-28.3 MCHC-31.5* RDW-13.1 RDWSD-43.0 Plt [MASKED] [MASKED] 09:35PM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 09:35PM BLOOD Glucose-326* UreaN-17 Creat-0.9 Na-135 K-5.7* Cl-94* HCO3-31 AnGap-16 [MASKED] 09:35PM BLOOD ALT-22 AST-44* AlkPhos-49 TotBili-0.2 [MASKED] 09:35PM BLOOD proBNP-447* [MASKED] 02:42AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.0 [MASKED] 09:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG [MASKED] 10:01PM BLOOD [MASKED] pO2-115* pCO2-67* pH-7.30* calTCO2-34* Base XS-3 Comment-GREEN TOP [MASKED] 10:01PM BLOOD O2 Sat-96 [MASKED] 06:46AM BLOOD Lactate-1.2 [MASKED] 02:42AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 02:42AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [MASKED] 02:42AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [MASKED] 02:42AM URINE CastHy-2* [MASKED] 02:42AM URINE Mucous-RARE ================= PERTINENT IMAGING ================= ------------------ CXR ([MASKED]): Evaluation is limited by low lung volumes and large body habitus. The lungs are grossly clear. Hila appear slightly congested. The heart and mediastinal contours appear mildly prominent likely due to supine portable technique. No supine evidence for large effusion or pneumothorax. Bony structures are intact. ------------------ ============== DISCHARGE LABS ============== [MASKED] 07:25AM BLOOD WBC-6.2 RBC-4.96 Hgb-14.6 Hct-45.5 MCV-92 MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-43.9 Plt [MASKED] [MASKED] 07:25AM BLOOD Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-31 AnGap-13 [MASKED] 07:25AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.[MASKED] with OSA, CHF, EtOH abuse who presents with an episode of apnea and hypercarbic respiratory failure in the context of recent attempt to detox from ETOH at [MASKED]. was witnessed to be altered and have a [MASKED] second episode of apnea while at [MASKED]. Had been starting Librium there. In ED given flumazenil x2, noted to be significantly altered and minimally responsive. Briefly admitted to the MICU where he was put on BiPAP and put on phenobarbital pathway. Respiratory failure resolved with BiPAP + O2 at night to avoid desaturations. He was medically detoxed from alcohol on the phenobarb taper. He was A&O x3 at discharge. MICU COURSE ----------- #Hypercarbic respiratory failure: Most likely multifactorial, depressed respiratory drive in the setting of benzodiazepine/potential other drug overdose, pulmonary edema secondary to possible heart failure, sleep apnea in the setting of no CPAP, and possible obstructive lung disease. Patient was treated with 80 mg IV Lasix with appropriate urine output. He was intermittently put on BiPAP with close monitoring of his respiratory status. #Acute encephalopathy: Most likely multifactorial due to hypercarbia, benzodiazepine/other toxic ingestion. Urine and serum tox screens were positive for benzodiazepines on admission, in the setting of Librium intake at his [MASKED] facility. #EtOH abuse: Treated with phenobarbital load and taper, with high dose IV thiamine, folate, and multivitamin. #Diabetes: Novolog was restarted once his mental status improved and he was tolerating po intake. ============= ACTIVE ISSUES ============= # HYPERCARBIC RESPIRATORY FAILURE: Improved with nightly BiPAP + O2, 3 rounds of 60mg IV Lasix. Was saturating well on room air and mentating well prior to discharge. - Home diuretics resumed - BiPAP at night with O2 # ETOH WITHDRAWAL: Completed phenobarbital taper on [MASKED]. Has been medically detoxified from alcohol. - Prescribed thiamine, folate, MVI. ===================== CHRONIC/STABLE ISSUES ===================== # ACUTE ENCEPHALOPATHY: Resolved with treatment of hypercarbic respiratory failure as above. - Treat respiratory failure as above - F/u blood cultures # CHEST PAIN: Brief episode of substernal CP. EKG without signs of active ischemia, troponin negative x2. # CONGESTIVE HEART FAILURE: Diuresed with Lasix 60mg IV x3 here, then euvolemic on home Lasix. - Home Lasix - Discharge weight: 112.6kg # DIABETES: - Home 70/30 insulin # h/o COPD: - Home fluticasone - Home albuterol # MEDICATION RECONCILIATION/?h/o CAD: - Continue home atorvastatin and baby ASA =================== TRANSITIONAL ISSUES =================== # CODE: Full # CONTACT: Sister [MASKED] [MASKED] [ ] MEDICATION CHANGES: - Added thiamine, MVI, folate PO [ ] ETOH WITHDRAWAL: - Medically detoxed from alcohol on phenobarb taper as of [MASKED]. - Continue to encourage efforts at abstinence. [ ] OBSTRUCTIVE SLEEP APNEA: - Pt with nighttime apnea and desaturations. Requires BiPAP with O2 to avoid nighttime desaturations and apnea. [ ] CONGESTIVE HEART FAILURE: - Discharge weight: 112.6kg >30 minutes coordinating discharge from the hospital Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 40 mg PO QHS 2. Furosemide 80 mg PO QAM 3. Lisinopril 40 mg PO DAILY 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Atorvastatin 80 mg PO QPM 6. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puff Q4H:PRN wheeze or SOB 7. Clotrimazole Cream 1 Appl TP BID 8. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 9. Aspirin 81 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Furosemide 40 mg PO QHS 7. Furosemide 80 mg PO QAM 8. Lisinopril 40 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puff Q4H:PRN wheeze or SOB Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: Alcohol withdrawal SECONDARY: Obstructive sleep apnea Congestive heart failure exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were seen in our hospital because people noticed you stopped breathing while at your alcohol detox [MASKED]. On arrival to the hospital, you were very sleepy. We gave you medications to reverse things that could be possibly contributing to your sleepiness, and then put you on a drug called "phenobarbital" to help detox you from alcohol. We also gave you a BiPAP machine and oxygen to use at night. At this point, you have been detoxed here and you are medically stable for Clinical Support Services. You have a history of obstructive sleep apnea, and need to be able to bring your CPAP machine and oxygen to whatever facility you enter. Please present this sheet, or an attached letter, to staff at your facility to let them know this. You have been started on new vitamins, "folate" and "thiamine." Please take these every day to help with your nutrition. Please continue to use your eyedrops as prescribed for one week. If you experience worsening vision changes, or your eye itching/discharge is not improved by that time, please call your primary care physician for further followup. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E1165", "Y929", "G4733", "I2510", "Z794" ]
[ "J9622: Acute and chronic respiratory failure with hypercapnia", "G9340: Encephalopathy, unspecified", "I501: Left ventricular failure, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D751: Secondary polycythemia", "F10239: Alcohol dependence with withdrawal, unspecified", "Z720: Tobacco use", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y929: Unspecified place or not applicable", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z794: Long term (current) use of insulin", "Z23: Encounter for immunization", "R0789: Other chest pain" ]
10,057,126
29,269,663
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___: Coronary angiography History of Present Illness: ___ man with history of aortic stenosis, CAD with NSTEMI ___ s/p bare metal stent to LAD, hypertension, multiple myeloma on lenalidomide presenting with 5 days of intermittent chest pain prior to transfer from ___. He first noticed discomfort in the right upper chest with exertion 5 days prior to admission which did not radiate and was associated with food. Tums did not alleviate his pain. He was seen by his cardiologist 1 day prior to admission and had blood work done; his cardiologist asked the patient to return for an appointment the day of admission where he underwent multiple stress tests. He states he "failed" 3 stress test, but his troponin was negative. He denied fever, chills, nausea, vomiting, diarrhea, shortness of breath, black or bloody stools, leg swelling, productive cough. On further discussion with PCP who had spoke with his cardiologist, patient had negative troponins but stress test with ST depressions at the office. In the emergency department, vital signs were unremarkable. Physical exam was notable for clear lungs, regular rate and rhythm, systolic murmur best heard at left upper sternal border. Labs were notable for WBC 2.9, normal BMP, elevated LFTs with ALT 53, AST 44, Total bili 0.5, lipase 16. proBNP 96. Troponin-T negative x1. EKG notable for sinus bradycardia, sub-millimeter ST depressions in lateral leads, downward deflections in the inferior leads that do not meet criteria for pathologic Q waves. The patient was given ASA 325 mg. After arrival to the cardiology ward, patient confirmed above history. He has been having pain for the last week on and off. He described the chest pain as right-sided, pressure, exacerbated by exertion. He stated that he had pain after walking into the cardiologist office this morning. The pain was relieved with 5 minutes of rest. He stated that this pain is different than when he had his prior MI which came on suddenly and was more severe. The pain is not associated with nausea, vomiting, palpitations, diaphoresis. At the time of interview and examination, he was chest pain free. There was no history of fever, chills, cough, shortness of breath, abdominal pain, dysuria, diarrhea, lower extremity edema, myalgia, arthralgia, rash. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, he denied 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, exertional buttock or calf pain, recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: 1. CAD RISK FACTORS -Hypertension -Dyslipidemia 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LAD ___ - PACING/ICD: None - Aortic stenosis 3. OTHER PAST MEDICAL HISTORY -Multiple myeloma -Neuropathy Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: On admission GENERAL: Well-developed, well-nourished elderly white man in NAD. Mood, affect appropriate. VITALS: ___ 2136 Temp: 97.7 PO BP: 127/79 HR: 57 RR: 18 O2 sat: 93% O2 delivery: RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, normal S1, S2; ___ murmur best heard at the right upper sternal border, radiates throughout the entire precordium. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric At discharge GENERAL: Well-appearing obese man, pleasant and conversive, no acute distress 24 HR Data (last updated ___ @ 1134) Temp: 97.9 (Tm 98.6), BP: 117/75 (115-137/72-78), HR: 60 (56-65), RR: 18 (___), O2 sat: 96% (94-97), O2 delivery: c-pap Fluid Balance (last updated ___ @ 605) Last 8 hours Total cumulative -450ml IN: Total 0ml OUT: Total 450ml, Urine Amt 450ml Last 24 hours Total cumulative -330ml IN: Total 720ml, PO Amt 720ml OUT: Total 1050ml, Urine Amt 1050ml CARDIAC: ___ late peaking systolic murmur heard best at RUSB with radiation throughout the precordium, JVP difficult to appreciate due to body habitus RESP: Clear to auscultation bilaterally ABD: No distended, non-tender, bowel sounds present EXT: No lower extremity edema, warm Pertinent Results: ___ 05:15PM BLOOD WBC-2.9* RBC-4.35* Hgb-13.5* Hct-41.0 MCV-94 MCH-31.0 MCHC-32.9 RDW-15.0 RDWSD-51.7* Plt ___ ___ 05:15PM BLOOD Neuts-39.5 ___ Monos-22.6* Eos-2.1 Baso-1.0 Im ___ AbsNeut-1.13* AbsLymp-0.99* AbsMono-0.65 AbsEos-0.06 AbsBaso-0.03 ___ 05:15PM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-142 K-4.0 Cl-100 HCO3-26 AnGap-16 ___ 05:15PM BLOOD ALT-53* AST-44* AlkPhos-45 TotBili-0.5 ___ 06:38AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.7 ___ 05:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 05:15PM BLOOD HCV Ab-NEG ___ 05:15PM BLOOD cTropnT-<0.01 proBNP-96 ___ 06:38AM BLOOD cTropnT-<0.01 ECG ___ 15:26:08 Sinus bradycardia. Nonspecific repol abnormality, lateral leads. No significant change Echocardiogram ___ The left atrial volume index is normal. The right atrium is mildly enlarged. 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 70 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). 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 mildly dilated ascending aorta. There is a normal descending aorta diameter. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). The effective orifice area index is SEVERELY reduced (less than 0.65 cm2/m2). There is mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are not well seen. 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. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Severe aortic valve stenosis with thickened/deformed leaflets and mild to moderate aortic regurgitation. Mild mitral regurgitation. Coronary angiography ___ Coronary anatomy LM: The left main coronary artery had mild distal plaquing. LAD: The left anterior descending coronary artery was calcified with a patent stent proximally. The ___ diagonal had a mild origin plaque. The major bifurcating medial pole of the D1 had a 75% stenosis just after the take-off of the smaller ___ lateral sidebranch of D1 and before the major bifurcation of that medial pole. The distal LAD wrapped slightly around the apex. Flow in the LAD was delayed and pulsatile consistent with microvascular dysfunction. Circ: The circumflex coronary artery gave off a tortuous high OM1. OM2 was small. The large tortuous LPL1/OM3 had an origin 30% plaque, a proximal-mid 80% stenosis followed by a 40% stenosis. Flow into the LPL was delayed and pulsatile. RCA: The dominant right coronary artery was calcified with a vertical origin with an origin 50% stenosis. The proximal RCA had a 40% stenosis followed by luminal irregularities and mild plaquing. The RPDA had delayed, pulsatile flow and multiple laterally oriented sidebranches. The distal RCA supplied several modest caliber RPLs and extended well up the left ventricle. Other: The aortic valve was heavily calcified. The thoracic aorta was unfolded. The right iliac artery was somewhat tortuous, prompting use of a 25 cm long introducing sheath. Findings: 1. Three vessel coronary artery disease. 2. Systemic arterial hypertension. Discharge labs ___ 07:54AM BLOOD WBC-3.7* RBC-4.34* Hgb-13.5* Hct-41.4 MCV-95 MCH-31.1 MCHC-32.6 RDW-14.9 RDWSD-51.9* Plt ___ ___ 07:54AM BLOOD Glucose-115* UreaN-17 Creat-1.2 Na-139 K-4.1 Cl-103 HCO3-20* AnGap-___ yo M with H/O CAD (s/p BMS of LAD in ___, hypertension, multiple myeloma (on lenalidomide, followed at ___, presenting with intermittent exertional, non-radiating chest tightness, likely due to severe aortic stenosis. Active Issues: # CAD, chest pain, severe aortic stenosis: Patient with reported T wave inversions on exercise stress ECG at cardiologist's office. Troponin reportedly negative there and negative x3 at ___. Echocardiogram showed severe aortic stenosis ___ 1 cm2, gradient 74 mm Hg peak and 47 mm Hg mean), mild to moderate aortic regurgitation, mild mitral regurgitation and preserved LVEF 70%. Coronary angiography showed with largely unchanged moderate 3 vessel coronary disease. He was seen by cardiac surgery and determined to be intermediate risk for surgical aortic valve repair. Patient desired to have TAVR but needs to have CTA. Given 110 mL contrast load during coronary angiography in patient with multiple myeloma and CKD stage 2 with eGFR 65, he will obtain CTA as an outpatient after his kidneys recover to lessen the chances of contrast nephropathy. He was continued on aspirin 81 mg PO daily, metoprolol 25 mg daily, and his atorvastatin was increased to 80 mg PO daily. # Mild Transaminitis: Patient admitted with ALT of 49 and AST of 38. No abdominal pain. LFTs now resolving. Hep B, Hep C serologies negative. Chronic issues # Leukopenia: Patient with ANC of 1130. Likely in the setting of ongoing treatment of multiple myeloma. # Multiple myeloma: Patient receives cancer care at ___ ___. On lenalidomide. # HSV/VZV suppression: On acyclovir 400mg transitioned to valcyclovir while inpatient. # Depression: Continued home paroxetine # Neuropathy: Continued home Lyrica and gabapentin # Obstructive sleep apnea: Continued CPAP while inpatient # Hypertension: Continued amlodipine 10 mg. Held home HCTZ given BP well controlled in house and to avoid intravascular volume depletion after contrast for coronary angiogram Transitional Issues [ ] please obtain outpatient CTA chest for continued TAVR evaluation [ ] Continue to address surgical vs TAVR [ ] HCTZ held on discharge, follow up blood pressures and resume as tolerated if renal function stable [ ] Check creatinine and potassium within 1 week to ensure stable [ ] Please avoid omeprazole due to FDA warning about drug-drug interaction with clopidogrel - pantoprazole is preferred PPI # CODE: Full (presumed) # CONTACT: ___ (wife) Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. colestipol 1 gram oral DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. PARoxetine 40 mg PO DAILY 7. Pyridoxine 50 mg PO DAILY 8. rOPINIRole 0.25 mg PO QPM 9. Neutra-Phos 1 PKT PO DAILY 10. Aspirin 325 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. Clopidogrel 75 mg PO DAILY 13. Gabapentin 600 mg PO TID 14. ValACYclovir 1000 mg PO Q24H 15. Pregabalin 50 mg PO TID 16. amLODIPine 10 mg PO DAILY 17. Metoprolol Succinate XL 25 mg PO DAILY 18. Cyanocobalamin 500 mcg PO DAILY 19. Lenalidomide 10 mg PO UNKNOWN Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. colestipol 1 gram oral DAILY 5. Cyanocobalamin 500 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. Lenalidomide 10 mg PO UNKNOWN 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Neutra-Phos 1 PKT PO DAILY 11. Omeprazole 20 mg PO DAILY 12. PARoxetine 40 mg PO DAILY 13. Pregabalin 50 mg PO TID 14. Pyridoxine 50 mg PO DAILY 15. rOPINIRole 0.25 mg PO QPM 16. ValACYclovir 1000 mg PO Q24H 17. Vitamin D 1000 UNIT PO DAILY 18. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you see your PCP ___: Home Discharge Diagnosis: -Unstable angina -Severe Aortic stenosis -Coronary artery disease -Leukopenia -Multiple myeloma -Hypertension -Stage 2 chronic kidney disease -Depression -Obstructive sleep apnea -Neuropathy -Abnormal liver function tests 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 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 were having chest pain WHAT HAPPENED IN THE HOSPITAL? ============================== - You had an Ultrasound of your heart that showed that one of the valves (Aortic valve) was very narrow. Your heart arteries were examined (cardiac catheterization), that found that 3 arteries had some blockage. You were evaluated the cardiac surgeons. You were think of surgical vs non surgical valve replacement, and decided for non surgical valve repair. You improved and were ready to leave the hospital. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Please weigh yourself every day in the morning. Call your doctor if your weight goes up or down by more than 3 lbs in a day or 5 Ibs in a week. Followup Instructions: ___
[ "I25110", "C9000", "Z6841", "I350", "I252", "E785", "Z955", "G629", "R740", "Z7901", "F329", "G4733", "I129", "N182", "R197", "E669" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED]: Coronary angiography History of Present Illness: [MASKED] man with history of aortic stenosis, CAD with NSTEMI [MASKED] s/p bare metal stent to LAD, hypertension, multiple myeloma on lenalidomide presenting with 5 days of intermittent chest pain prior to transfer from [MASKED]. He first noticed discomfort in the right upper chest with exertion 5 days prior to admission which did not radiate and was associated with food. Tums did not alleviate his pain. He was seen by his cardiologist 1 day prior to admission and had blood work done; his cardiologist asked the patient to return for an appointment the day of admission where he underwent multiple stress tests. He states he "failed" 3 stress test, but his troponin was negative. He denied fever, chills, nausea, vomiting, diarrhea, shortness of breath, black or bloody stools, leg swelling, productive cough. On further discussion with PCP who had spoke with his cardiologist, patient had negative troponins but stress test with ST depressions at the office. In the emergency department, vital signs were unremarkable. Physical exam was notable for clear lungs, regular rate and rhythm, systolic murmur best heard at left upper sternal border. Labs were notable for WBC 2.9, normal BMP, elevated LFTs with ALT 53, AST 44, Total bili 0.5, lipase 16. proBNP 96. Troponin-T negative x1. EKG notable for sinus bradycardia, sub-millimeter ST depressions in lateral leads, downward deflections in the inferior leads that do not meet criteria for pathologic Q waves. The patient was given ASA 325 mg. After arrival to the cardiology ward, patient confirmed above history. He has been having pain for the last week on and off. He described the chest pain as right-sided, pressure, exacerbated by exertion. He stated that he had pain after walking into the cardiologist office this morning. The pain was relieved with 5 minutes of rest. He stated that this pain is different than when he had his prior MI which came on suddenly and was more severe. The pain is not associated with nausea, vomiting, palpitations, diaphoresis. At the time of interview and examination, he was chest pain free. There was no history of fever, chills, cough, shortness of breath, abdominal pain, dysuria, diarrhea, lower extremity edema, myalgia, arthralgia, rash. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, he denied 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, exertional buttock or calf pain, recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: 1. CAD RISK FACTORS -Hypertension -Dyslipidemia 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LAD [MASKED] - PACING/ICD: None - Aortic stenosis 3. OTHER PAST MEDICAL HISTORY -Multiple myeloma -Neuropathy Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: On admission GENERAL: Well-developed, well-nourished elderly white man in NAD. Mood, affect appropriate. VITALS: [MASKED] 2136 Temp: 97.7 PO BP: 127/79 HR: 57 RR: 18 O2 sat: 93% O2 delivery: RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RRR, normal S1, S2; [MASKED] murmur best heard at the right upper sternal border, radiates throughout the entire precordium. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric At discharge GENERAL: Well-appearing obese man, pleasant and conversive, no acute distress 24 HR Data (last updated [MASKED] @ 1134) Temp: 97.9 (Tm 98.6), BP: 117/75 (115-137/72-78), HR: 60 (56-65), RR: 18 ([MASKED]), O2 sat: 96% (94-97), O2 delivery: c-pap Fluid Balance (last updated [MASKED] @ 605) Last 8 hours Total cumulative -450ml IN: Total 0ml OUT: Total 450ml, Urine Amt 450ml Last 24 hours Total cumulative -330ml IN: Total 720ml, PO Amt 720ml OUT: Total 1050ml, Urine Amt 1050ml CARDIAC: [MASKED] late peaking systolic murmur heard best at RUSB with radiation throughout the precordium, JVP difficult to appreciate due to body habitus RESP: Clear to auscultation bilaterally ABD: No distended, non-tender, bowel sounds present EXT: No lower extremity edema, warm Pertinent Results: [MASKED] 05:15PM BLOOD WBC-2.9* RBC-4.35* Hgb-13.5* Hct-41.0 MCV-94 MCH-31.0 MCHC-32.9 RDW-15.0 RDWSD-51.7* Plt [MASKED] [MASKED] 05:15PM BLOOD Neuts-39.5 [MASKED] Monos-22.6* Eos-2.1 Baso-1.0 Im [MASKED] AbsNeut-1.13* AbsLymp-0.99* AbsMono-0.65 AbsEos-0.06 AbsBaso-0.03 [MASKED] 05:15PM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-142 K-4.0 Cl-100 HCO3-26 AnGap-16 [MASKED] 05:15PM BLOOD ALT-53* AST-44* AlkPhos-45 TotBili-0.5 [MASKED] 06:38AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.7 [MASKED] 05:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 05:15PM BLOOD HCV Ab-NEG [MASKED] 05:15PM BLOOD cTropnT-<0.01 proBNP-96 [MASKED] 06:38AM BLOOD cTropnT-<0.01 ECG [MASKED] 15:26:08 Sinus bradycardia. Nonspecific repol abnormality, lateral leads. No significant change Echocardiogram [MASKED] The left atrial volume index is normal. The right atrium is mildly enlarged. 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 70 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). 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 mildly dilated ascending aorta. There is a normal descending aorta diameter. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). The effective orifice area index is SEVERELY reduced (less than 0.65 cm2/m2). There is mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are not well seen. 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. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Severe aortic valve stenosis with thickened/deformed leaflets and mild to moderate aortic regurgitation. Mild mitral regurgitation. Coronary angiography [MASKED] Coronary anatomy LM: The left main coronary artery had mild distal plaquing. LAD: The left anterior descending coronary artery was calcified with a patent stent proximally. The [MASKED] diagonal had a mild origin plaque. The major bifurcating medial pole of the D1 had a 75% stenosis just after the take-off of the smaller [MASKED] lateral sidebranch of D1 and before the major bifurcation of that medial pole. The distal LAD wrapped slightly around the apex. Flow in the LAD was delayed and pulsatile consistent with microvascular dysfunction. Circ: The circumflex coronary artery gave off a tortuous high OM1. OM2 was small. The large tortuous LPL1/OM3 had an origin 30% plaque, a proximal-mid 80% stenosis followed by a 40% stenosis. Flow into the LPL was delayed and pulsatile. RCA: The dominant right coronary artery was calcified with a vertical origin with an origin 50% stenosis. The proximal RCA had a 40% stenosis followed by luminal irregularities and mild plaquing. The RPDA had delayed, pulsatile flow and multiple laterally oriented sidebranches. The distal RCA supplied several modest caliber RPLs and extended well up the left ventricle. Other: The aortic valve was heavily calcified. The thoracic aorta was unfolded. The right iliac artery was somewhat tortuous, prompting use of a 25 cm long introducing sheath. Findings: 1. Three vessel coronary artery disease. 2. Systemic arterial hypertension. Discharge labs [MASKED] 07:54AM BLOOD WBC-3.7* RBC-4.34* Hgb-13.5* Hct-41.4 MCV-95 MCH-31.1 MCHC-32.6 RDW-14.9 RDWSD-51.9* Plt [MASKED] [MASKED] 07:54AM BLOOD Glucose-115* UreaN-17 Creat-1.2 Na-139 K-4.1 Cl-103 HCO3-20* AnGap-[MASKED] yo M with H/O CAD (s/p BMS of LAD in [MASKED], hypertension, multiple myeloma (on lenalidomide, followed at [MASKED], presenting with intermittent exertional, non-radiating chest tightness, likely due to severe aortic stenosis. Active Issues: # CAD, chest pain, severe aortic stenosis: Patient with reported T wave inversions on exercise stress ECG at cardiologist's office. Troponin reportedly negative there and negative x3 at [MASKED]. Echocardiogram showed severe aortic stenosis [MASKED] 1 cm2, gradient 74 mm Hg peak and 47 mm Hg mean), mild to moderate aortic regurgitation, mild mitral regurgitation and preserved LVEF 70%. Coronary angiography showed with largely unchanged moderate 3 vessel coronary disease. He was seen by cardiac surgery and determined to be intermediate risk for surgical aortic valve repair. Patient desired to have TAVR but needs to have CTA. Given 110 mL contrast load during coronary angiography in patient with multiple myeloma and CKD stage 2 with eGFR 65, he will obtain CTA as an outpatient after his kidneys recover to lessen the chances of contrast nephropathy. He was continued on aspirin 81 mg PO daily, metoprolol 25 mg daily, and his atorvastatin was increased to 80 mg PO daily. # Mild Transaminitis: Patient admitted with ALT of 49 and AST of 38. No abdominal pain. LFTs now resolving. Hep B, Hep C serologies negative. Chronic issues # Leukopenia: Patient with ANC of 1130. Likely in the setting of ongoing treatment of multiple myeloma. # Multiple myeloma: Patient receives cancer care at [MASKED] [MASKED]. On lenalidomide. # HSV/VZV suppression: On acyclovir 400mg transitioned to valcyclovir while inpatient. # Depression: Continued home paroxetine # Neuropathy: Continued home Lyrica and gabapentin # Obstructive sleep apnea: Continued CPAP while inpatient # Hypertension: Continued amlodipine 10 mg. Held home HCTZ given BP well controlled in house and to avoid intravascular volume depletion after contrast for coronary angiogram Transitional Issues [ ] please obtain outpatient CTA chest for continued TAVR evaluation [ ] Continue to address surgical vs TAVR [ ] HCTZ held on discharge, follow up blood pressures and resume as tolerated if renal function stable [ ] Check creatinine and potassium within 1 week to ensure stable [ ] Please avoid omeprazole due to FDA warning about drug-drug interaction with clopidogrel - pantoprazole is preferred PPI # CODE: Full (presumed) # CONTACT: [MASKED] (wife) Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. colestipol 1 gram oral DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. PARoxetine 40 mg PO DAILY 7. Pyridoxine 50 mg PO DAILY 8. rOPINIRole 0.25 mg PO QPM 9. Neutra-Phos 1 PKT PO DAILY 10. Aspirin 325 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. Clopidogrel 75 mg PO DAILY 13. Gabapentin 600 mg PO TID 14. ValACYclovir 1000 mg PO Q24H 15. Pregabalin 50 mg PO TID 16. amLODIPine 10 mg PO DAILY 17. Metoprolol Succinate XL 25 mg PO DAILY 18. Cyanocobalamin 500 mcg PO DAILY 19. Lenalidomide 10 mg PO UNKNOWN Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. colestipol 1 gram oral DAILY 5. Cyanocobalamin 500 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. Lenalidomide 10 mg PO UNKNOWN 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Neutra-Phos 1 PKT PO DAILY 11. Omeprazole 20 mg PO DAILY 12. PARoxetine 40 mg PO DAILY 13. Pregabalin 50 mg PO TID 14. Pyridoxine 50 mg PO DAILY 15. rOPINIRole 0.25 mg PO QPM 16. ValACYclovir 1000 mg PO Q24H 17. Vitamin D 1000 UNIT PO DAILY 18. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you see your PCP [MASKED]: Home Discharge Diagnosis: -Unstable angina -Severe Aortic stenosis -Coronary artery disease -Leukopenia -Multiple myeloma -Hypertension -Stage 2 chronic kidney disease -Depression -Obstructive sleep apnea -Neuropathy -Abnormal liver function tests 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 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 were having chest pain WHAT HAPPENED IN THE HOSPITAL? ============================== - You had an Ultrasound of your heart that showed that one of the valves (Aortic valve) was very narrow. Your heart arteries were examined (cardiac catheterization), that found that 3 arteries had some blockage. You were evaluated the cardiac surgeons. You were think of surgical vs non surgical valve replacement, and decided for non surgical valve repair. You improved and were ready to leave the hospital. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Please weigh yourself every day in the morning. Call your doctor if your weight goes up or down by more than 3 lbs in a day or 5 Ibs in a week. Followup Instructions: [MASKED]
[]
[ "I252", "E785", "Z955", "Z7901", "F329", "G4733", "I129", "E669" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "C9000: Multiple myeloma not having achieved remission", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I350: Nonrheumatic aortic (valve) stenosis", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "G629: Polyneuropathy, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z7901: Long term (current) use of anticoagulants", "F329: Major depressive disorder, single episode, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "R197: Diarrhea, unspecified", "E669: Obesity, unspecified" ]
10,057,126
29,719,322
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p ___ 3 TAVR ___ History of Present Illness: ___ is a ___ year old man with severe aortic stenosis, coronary artery disease, hypertension, multiple myeloma (well-controlled), and obesity. He has had intermittent exertional chest pain and shortness of breath for the last several months but has reliably resolved with rest. His PCP obtained ___ stress test which was abnormal and he was admitted to ___ from ___ to ___. He had a cardiac catheterization, which showed unchanged coronary artery disease. His symptoms were largely related to his severe aortic stenosis. He was seen by Cardiac surgery and deemed an intermediate surgical risk for aortic valve replacement. He presents today for TAVR. NYHA Class: III Past Medical History: 1. Severe aortic stenosis 2. Multiple myeloma (well controlled) 3. Hypertension 4. Obesity 5. Coronary artery disease (BMS to LAD ___ 6. Neuropathy Social History: ___ Family History: No history of familial disease Physical Exam: ADMISSION PE: =============== VS: BP 99/59, HR 52, RR 14, O2 sat 94% on room air Weight: 253.99 lbs Tele: ___, SB EKG: rate 49, SB Gen: Lying in bed, in no distress Neuro: Awake and alert. Orinted on first exam. NP was called in to see pt with c/o memory deficits. Patient could not remember month, date or year. Does not know the President of ___.S. PERRLA. Tongue midline. Strength equal in all extremities. No other deficits noted other than memory deficit. Balance could not be checked due to bedrest post-op. Neck: No LAD, no JVD CV: RRR. Nl S1S2. Soft SEM. Chest: Respirations unlabored. CTA anteriorly ABD: Soft, NT, ND Extr: MAE. Trace ___ edema Skin: No rashes or ulcers noted Access sites: ___ groin sites soft without ooze, ecchymosis or hematoma. Left groin had a small ooze, 5 mins manual pressure applied. ___ palpable DISCHARGE PE: ============== Weight: Pertinent Results: ADMISSION LABS: =============== ___ 03:47PM BLOOD WBC-2.6* RBC-3.76* Hgb-11.9* Hct-35.3* MCV-94 MCH-31.6 MCHC-33.7 RDW-14.7 RDWSD-50.7* Plt ___ ___ 03:47PM BLOOD ___ PTT-31.9 ___ ___ 03:47PM BLOOD Glucose-101* UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-11 ___ 03:47PM BLOOD Calcium-8.1* Phos-2.8 Mg-1.7 Discharge Labs: =================== ___ 07:22AM BLOOD WBC-4.3 RBC-3.81* Hgb-12.0* Hct-36.5* MCV-96 MCH-31.5 MCHC-32.9 RDW-14.8 RDWSD-51.8* Plt ___ ___ 05:51AM BLOOD UreaN-14 Creat-1.1 Na-142 K-3.7 Cl-102 HCO3-23 AnGap-17 ___ 07:22AM BLOOD Mg-1.8 ___ 05:51AM BLOOD Triglyc-250* HDL-42 CHOL/HD-2.7 LDLcalc-23 IMAGING: ======== TTE ___: ============= CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. 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 69 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with a mildly dilated ascending aorta. The aortic arch is mildly dilated with a normal descending aorta diameter. A ___ 3 aortic valve bioprosthesis is present. The prosthesis is well seated with Leaflets not well seen with high gradient. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal 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 physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of ___ , gradient is higher. TTE: ___ (intra operative) CONCLUSION: Pre-TAVR: There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is mild [1+] aortic regurgitation. Post-TAVR: The ___ 3 TAVR prosthesis is well seated with normal leaflet motion and normal gradient. There is a paravalvular jet of trace aortic regurgitation is seen. MEASUREMENTS: AORTIC VALVE Peak Velocity: 1.6m/sec (nl<=2.0) Peak Gradient: 10mmHg Mean Gradient: 4mmHg AV VTI: 35cm Post TAVR Peak Velocity: 1.6m/sec Post TAVR Peak Gradient: 10mmHg Post TAVR Mean Gradient:4mmHg ***CT HEAD W/O CONTRAST: ___ FINDINGS: There is no evidence of recent territorial infarct,intracranial hemorrhage,edema,or mass. There is mild prominence of the ventricles and sulci suggestive of involutional changes. No evidence of calvarial fracture. Mild mucosal thickening of the ethmoidal air cells. The maxillary sinuses and mastoid air cells are clear. The orbits are unremarkable. IMPRESSION: 1. No evidence of recent territorial infarct. No acute intracranial process. ***EEG: (DATE) pending MRI BRAIN: ___ There are multiple scattered foci of slow diffusion involving the bilateral frontal, left parietal, and left occipital lobes with multiple foci of slow diffusion in the right cerebellar hemisphere. There are mild periventricular and subcortical foci of white matter T2/FLAIR signal hyperintensity, nonspecific but likely sequelae of chronic small vessel disease. There is no evidence of hemorrhage,edema,masses, mass effect,or midline shift. The ventricles and sulci are mildly prominent suggesting age-related involutional changes. The major intracranial vascular flow voids are preserved. Orbits and visualized extracranial soft tissues are unremarkable. MRA BRAIN: Images are significantly motion degraded. There is possible multifocal narrowing of the bilateral posterior cerebral arteries with a fetal type origin of the right posterior cerebral artery, with assessment limited by motion artifact. However, this is not verified on the postcontrast MRA of the neck which includes the proximal posterior circulation.. There is mild atheromatous narrowing of the bilateral intracranial ICA and the distal MCA branches. The intracranial vertebral and internal carotid arteries and their major branches otherwise appear normal without evidence of stenosis,occlusion,or aneurysm formation. MRA NECK: The right vertebral artery is diffusely small in caliber, anatomic variant, with dominant left vertebral artery. There is possibly mild narrowing in the A1 segment at the right vertebral artery origin. Otherwise, both vertebral arteries appear patent with no significant stenosis demonstrated. Narrowing. There is irregular narrowing at the bilateral common carotid artery bifurcations with mild stenosis at the origin of the left internal carotid artery and moderate stenosis at the origin of the right external carotid artery. The origins of the great vessels, subclavian and vertebral arteries otherwise appear patent bilaterally. The common, internal and external carotid arteries otherwise appear patent. IMPRESSION: 1. Multiple scattered acute to subacute infarcts right cerebellar hemisphere, bilateral frontal, left parietal and left occipital lobes suspicious for a cardioembolic etiology.. 2. Significantly motion degraded images of the intracranial arteries. 3. Within the above-mentioned confines, there is mild atheromatous narrowing of the bilateral intracranial ICA and distal MCA branches with some areas of possible narrowing of the bilateral posterior cerebral arteries, which appear less pronounced on the postcontrast images and therefore probably exaggerated by motion artifact.. 4. Otherwise patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 5. Mild atheromatous narrowing the bilateral common carotid bifurcations with mild stenosis of the left internal carotid artery origin. 6. Mild multifocal narrowing of the right cervical vertebral artery. 7. Small caliber right vertebral artery and dominant left vertebral artery, anatomic variant. 8. Otherwise patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. PROCEDURE: ========== TAVR: ___ Gradients: Pre-Procedure AV mean grad 47mmHg Interventional Details The patient was counseled extensively regarding the risks, benefits, and alternatives to the procedure and after answering all questions, the patient yielded informed consent. The patient was thereafter brought to the catheterization laboratory and monitored anesthesia care was delivered. Preprocedural antibiotic was administered intravenously. The nature of this procedure required multidisciplinary planning and management with the cardiac surgery, interventional cardiology and anesthesia physicians. All members of the heart team were present for the following key components of the procedure according ___ guidelines: Vascular access Catheter placement, Device implantation, Vascular closure, Intraprocedural medication ordering. Sterile technique was used throughout the case. All vascular access was obtained using modified Seldinger technique and ultrasound guidance. An ___ sheath was placed in the left femoral vein and ___ sheaths were placed in the right and left femoral artery. The ___ sheath in the right femoral artery was removed and the arteriotomy was measured with the Manta device, and the access site was upsized to an ___ sheath. A ___ Angled Pigtail catheter was advanced to the aortic root via the left femoral artery sheath and aortic root angiography was performed. A temporary pacing wire was placed in the right ventricle via the left femoral vein sheath. Next, the ___ sheath in the right femoral artery was exchanged over an Amplatz Extrastiff for the ___ sheath. A pigtail catheter was advanced to the aortic root. Using a 0.035" straight wire, the aortic valve was crossed. Over the wire, the angled pigtail catheter was advanced across the valve. Baseline hemodynamics (left heart catheterization) were obtained. A preshaped curved wire was advanced into the LV and the Al-1 catheter was removed. Next, the ___ delivery system was delivered to the descending aorta and the balloon positioned within the valve. We then proceeded to advance the ___ valve to the ascending aorta and to cross the aortic valve in a retrograde fashion. After confirming appropriate placement across the aortic valve using aortic root angiogaphy, the ___ valve was deployed with rapid ventricular pacing at 180 bpm. Complications There were no clinically significant complications. Brief Hospital Course: Assessment/Plan: ___ with severe symptomatic aortic stenosis, admitted s/p TAVR c/b small punctate scattered acute embolic stroke. # ___: Patient awake, alert and oriented post-op. Patient had transient memory deficit for 45 mins post-op in pacu. Could not recall surgery, why he is here, what's being done, month, year, president of the country etc. Neuro exam stable except for memory deficit yesterday. CT head negative for bleed. Neuro exam completely stable today. Memory generally intact. See above for MRI/MRA results. Pt and wife updated at bedside and neurology team informed. - Swallow evel done by RN, all ok - lipid panel at goal - A1C nl - neuro checks stable. - ___ ordered and found no deficits - EEG results pending - Continue daily aspirin and Plavix - Continue high dose statin # Severe aortic stenosis: S/P ___ 3 TAVR. Pre-echo peak/mean gradient 74/47mmHg; ___ 1.0cm2. Post TAVR PG/MG: ___, ___ 2.0 -AC plan: Aspirin 81 mg/Plavix 75 mg -SBE instructions on discharge -F/u Echo and SH appt in 1 month to be scheduled # Coronary artery disease: no chest pain -Continue aspirin, statin -Resumed metoprolol Chronic issues ============== #Leukopenia Patient with ANC of 1130. Likely in the setting of ongoing treatment of multiple myeloma. #Multiple myeloma Patient receives cancer care at ___. On Revlimid. #HSV/VZV suppression - On acyclovir #Depression - Continue home paroxetine #Neuropathy - Continue home gabapentin #Obstructive sleep apnea uses CPAP #Hypertension: Well controlled on HCTZ and amlodipine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. sod phos di, mono-K phos mono ___ mg oral TID 2. Gabapentin 600 mg PO TID 3. Lenalidomide 10 mg po EVERY ___ 4. Metoprolol Succinate XL 25 mg PO DAILY 5. colestipol 1 gram oral BID 6. amLODIPine 10 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. rOPINIRole 0.5 mg PO QAM 9. rOPINIRole 0.25 mg PO QPM 10. ValACYclovir 1000 mg PO Q24H 11. Clopidogrel 75 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. PARoxetine 40 mg PO DAILY 15. Hydrochlorothiazide 12.5 mg PO DAILY 16. Cyanocobalamin 500 mcg PO DAILY 17. FoLIC Acid 1 mg PO DAILY 18. Pyridoxine 50 mg PO DAILY 19. Vitamin D ___ UNIT PO 1X/WEEK (MO) 20. Furosemide 40 mg PO DAILY:PRN weight gain 21. Pregabalin 50 mg PO TID Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. Furosemide 40 mg PO DAILY weight gain Take every day for now after the TAVR 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. colestipol 1 gram oral BID 8. Cyanocobalamin 500 mcg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 600 mg PO TID 11. Hydrochlorothiazide 12.5 mg PO DAILY 12. Lenalidomide 10 mg po EVERY ___ 13. Metoprolol Succinate XL 25 mg PO DAILY 14. PARoxetine 40 mg PO DAILY 15. Pregabalin 50 mg PO TID 16. Pyridoxine 50 mg PO DAILY 17. rOPINIRole 0.25 mg PO QPM 18. rOPINIRole 0.5 mg PO QAM 19. sod phos di, mono-K phos mono ___ mg oral TID 20. ValACYclovir 1000 mg PO Q24H 21. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: Severe AS s/p TAVR HTN CAD Embolic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (TAVR) to treat your aortic valve stenosis which was done on ___. By repairing the valve your heart can pump blood more easily and your chest pain should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking Aspirin and Clopidogrel (Plavix). These medications help to prevent blood clots from forming on the new valve. If you stop these medications or miss ___ dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 252 pounds. We may have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call ___. 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 ___ Heart Line 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: ___
[ "I350", "I6340", "I5032", "C9000", "Z6841", "Z006", "Z23", "I2510", "I110", "Z955", "F329", "G629", "G4733", "E669", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p [MASKED] 3 TAVR [MASKED] History of Present Illness: [MASKED] is a [MASKED] year old man with severe aortic stenosis, coronary artery disease, hypertension, multiple myeloma (well-controlled), and obesity. He has had intermittent exertional chest pain and shortness of breath for the last several months but has reliably resolved with rest. His PCP obtained [MASKED] stress test which was abnormal and he was admitted to [MASKED] from [MASKED] to [MASKED]. He had a cardiac catheterization, which showed unchanged coronary artery disease. His symptoms were largely related to his severe aortic stenosis. He was seen by Cardiac surgery and deemed an intermediate surgical risk for aortic valve replacement. He presents today for TAVR. NYHA Class: III Past Medical History: 1. Severe aortic stenosis 2. Multiple myeloma (well controlled) 3. Hypertension 4. Obesity 5. Coronary artery disease (BMS to LAD [MASKED] 6. Neuropathy Social History: [MASKED] Family History: No history of familial disease Physical Exam: ADMISSION PE: =============== VS: BP 99/59, HR 52, RR 14, O2 sat 94% on room air Weight: 253.99 lbs Tele: [MASKED], SB EKG: rate 49, SB Gen: Lying in bed, in no distress Neuro: Awake and alert. Orinted on first exam. NP was called in to see pt with c/o memory deficits. Patient could not remember month, date or year. Does not know the President of [MASKED].S. PERRLA. Tongue midline. Strength equal in all extremities. No other deficits noted other than memory deficit. Balance could not be checked due to bedrest post-op. Neck: No LAD, no JVD CV: RRR. Nl S1S2. Soft SEM. Chest: Respirations unlabored. CTA anteriorly ABD: Soft, NT, ND Extr: MAE. Trace [MASKED] edema Skin: No rashes or ulcers noted Access sites: [MASKED] groin sites soft without ooze, ecchymosis or hematoma. Left groin had a small ooze, 5 mins manual pressure applied. [MASKED] palpable DISCHARGE PE: ============== Weight: Pertinent Results: ADMISSION LABS: =============== [MASKED] 03:47PM BLOOD WBC-2.6* RBC-3.76* Hgb-11.9* Hct-35.3* MCV-94 MCH-31.6 MCHC-33.7 RDW-14.7 RDWSD-50.7* Plt [MASKED] [MASKED] 03:47PM BLOOD [MASKED] PTT-31.9 [MASKED] [MASKED] 03:47PM BLOOD Glucose-101* UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-11 [MASKED] 03:47PM BLOOD Calcium-8.1* Phos-2.8 Mg-1.7 Discharge Labs: =================== [MASKED] 07:22AM BLOOD WBC-4.3 RBC-3.81* Hgb-12.0* Hct-36.5* MCV-96 MCH-31.5 MCHC-32.9 RDW-14.8 RDWSD-51.8* Plt [MASKED] [MASKED] 05:51AM BLOOD UreaN-14 Creat-1.1 Na-142 K-3.7 Cl-102 HCO3-23 AnGap-17 [MASKED] 07:22AM BLOOD Mg-1.8 [MASKED] 05:51AM BLOOD Triglyc-250* HDL-42 CHOL/HD-2.7 LDLcalc-23 IMAGING: ======== TTE [MASKED]: ============= CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. 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 69 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with a mildly dilated ascending aorta. The aortic arch is mildly dilated with a normal descending aorta diameter. A [MASKED] 3 aortic valve bioprosthesis is present. The prosthesis is well seated with Leaflets not well seen with high gradient. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal 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 physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of [MASKED] , gradient is higher. TTE: [MASKED] (intra operative) CONCLUSION: Pre-TAVR: There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is mild [1+] aortic regurgitation. Post-TAVR: The [MASKED] 3 TAVR prosthesis is well seated with normal leaflet motion and normal gradient. There is a paravalvular jet of trace aortic regurgitation is seen. MEASUREMENTS: AORTIC VALVE Peak Velocity: 1.6m/sec (nl<=2.0) Peak Gradient: 10mmHg Mean Gradient: 4mmHg AV VTI: 35cm Post TAVR Peak Velocity: 1.6m/sec Post TAVR Peak Gradient: 10mmHg Post TAVR Mean Gradient:4mmHg ***CT HEAD W/O CONTRAST: [MASKED] FINDINGS: There is no evidence of recent territorial infarct,intracranial hemorrhage,edema,or mass. There is mild prominence of the ventricles and sulci suggestive of involutional changes. No evidence of calvarial fracture. Mild mucosal thickening of the ethmoidal air cells. The maxillary sinuses and mastoid air cells are clear. The orbits are unremarkable. IMPRESSION: 1. No evidence of recent territorial infarct. No acute intracranial process. ***EEG: (DATE) pending MRI BRAIN: [MASKED] There are multiple scattered foci of slow diffusion involving the bilateral frontal, left parietal, and left occipital lobes with multiple foci of slow diffusion in the right cerebellar hemisphere. There are mild periventricular and subcortical foci of white matter T2/FLAIR signal hyperintensity, nonspecific but likely sequelae of chronic small vessel disease. There is no evidence of hemorrhage,edema,masses, mass effect,or midline shift. The ventricles and sulci are mildly prominent suggesting age-related involutional changes. The major intracranial vascular flow voids are preserved. Orbits and visualized extracranial soft tissues are unremarkable. MRA BRAIN: Images are significantly motion degraded. There is possible multifocal narrowing of the bilateral posterior cerebral arteries with a fetal type origin of the right posterior cerebral artery, with assessment limited by motion artifact. However, this is not verified on the postcontrast MRA of the neck which includes the proximal posterior circulation.. There is mild atheromatous narrowing of the bilateral intracranial ICA and the distal MCA branches. The intracranial vertebral and internal carotid arteries and their major branches otherwise appear normal without evidence of stenosis,occlusion,or aneurysm formation. MRA NECK: The right vertebral artery is diffusely small in caliber, anatomic variant, with dominant left vertebral artery. There is possibly mild narrowing in the A1 segment at the right vertebral artery origin. Otherwise, both vertebral arteries appear patent with no significant stenosis demonstrated. Narrowing. There is irregular narrowing at the bilateral common carotid artery bifurcations with mild stenosis at the origin of the left internal carotid artery and moderate stenosis at the origin of the right external carotid artery. The origins of the great vessels, subclavian and vertebral arteries otherwise appear patent bilaterally. The common, internal and external carotid arteries otherwise appear patent. IMPRESSION: 1. Multiple scattered acute to subacute infarcts right cerebellar hemisphere, bilateral frontal, left parietal and left occipital lobes suspicious for a cardioembolic etiology.. 2. Significantly motion degraded images of the intracranial arteries. 3. Within the above-mentioned confines, there is mild atheromatous narrowing of the bilateral intracranial ICA and distal MCA branches with some areas of possible narrowing of the bilateral posterior cerebral arteries, which appear less pronounced on the postcontrast images and therefore probably exaggerated by motion artifact.. 4. Otherwise patent circle of [MASKED] without evidence of stenosis,occlusion,or aneurysm. 5. Mild atheromatous narrowing the bilateral common carotid bifurcations with mild stenosis of the left internal carotid artery origin. 6. Mild multifocal narrowing of the right cervical vertebral artery. 7. Small caliber right vertebral artery and dominant left vertebral artery, anatomic variant. 8. Otherwise patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. PROCEDURE: ========== TAVR: [MASKED] Gradients: Pre-Procedure AV mean grad 47mmHg Interventional Details The patient was counseled extensively regarding the risks, benefits, and alternatives to the procedure and after answering all questions, the patient yielded informed consent. The patient was thereafter brought to the catheterization laboratory and monitored anesthesia care was delivered. Preprocedural antibiotic was administered intravenously. The nature of this procedure required multidisciplinary planning and management with the cardiac surgery, interventional cardiology and anesthesia physicians. All members of the heart team were present for the following key components of the procedure according [MASKED] guidelines: Vascular access Catheter placement, Device implantation, Vascular closure, Intraprocedural medication ordering. Sterile technique was used throughout the case. All vascular access was obtained using modified Seldinger technique and ultrasound guidance. An [MASKED] sheath was placed in the left femoral vein and [MASKED] sheaths were placed in the right and left femoral artery. The [MASKED] sheath in the right femoral artery was removed and the arteriotomy was measured with the Manta device, and the access site was upsized to an [MASKED] sheath. A [MASKED] Angled Pigtail catheter was advanced to the aortic root via the left femoral artery sheath and aortic root angiography was performed. A temporary pacing wire was placed in the right ventricle via the left femoral vein sheath. Next, the [MASKED] sheath in the right femoral artery was exchanged over an Amplatz Extrastiff for the [MASKED] sheath. A pigtail catheter was advanced to the aortic root. Using a 0.035" straight wire, the aortic valve was crossed. Over the wire, the angled pigtail catheter was advanced across the valve. Baseline hemodynamics (left heart catheterization) were obtained. A preshaped curved wire was advanced into the LV and the Al-1 catheter was removed. Next, the [MASKED] delivery system was delivered to the descending aorta and the balloon positioned within the valve. We then proceeded to advance the [MASKED] valve to the ascending aorta and to cross the aortic valve in a retrograde fashion. After confirming appropriate placement across the aortic valve using aortic root angiogaphy, the [MASKED] valve was deployed with rapid ventricular pacing at 180 bpm. Complications There were no clinically significant complications. Brief Hospital Course: Assessment/Plan: [MASKED] with severe symptomatic aortic stenosis, admitted s/p TAVR c/b small punctate scattered acute embolic stroke. # [MASKED]: Patient awake, alert and oriented post-op. Patient had transient memory deficit for 45 mins post-op in pacu. Could not recall surgery, why he is here, what's being done, month, year, president of the country etc. Neuro exam stable except for memory deficit yesterday. CT head negative for bleed. Neuro exam completely stable today. Memory generally intact. See above for MRI/MRA results. Pt and wife updated at bedside and neurology team informed. - Swallow evel done by RN, all ok - lipid panel at goal - A1C nl - neuro checks stable. - [MASKED] ordered and found no deficits - EEG results pending - Continue daily aspirin and Plavix - Continue high dose statin # Severe aortic stenosis: S/P [MASKED] 3 TAVR. Pre-echo peak/mean gradient 74/47mmHg; [MASKED] 1.0cm2. Post TAVR PG/MG: [MASKED], [MASKED] 2.0 -AC plan: Aspirin 81 mg/Plavix 75 mg -SBE instructions on discharge -F/u Echo and SH appt in 1 month to be scheduled # Coronary artery disease: no chest pain -Continue aspirin, statin -Resumed metoprolol Chronic issues ============== #Leukopenia Patient with ANC of 1130. Likely in the setting of ongoing treatment of multiple myeloma. #Multiple myeloma Patient receives cancer care at [MASKED]. On Revlimid. #HSV/VZV suppression - On acyclovir #Depression - Continue home paroxetine #Neuropathy - Continue home gabapentin #Obstructive sleep apnea uses CPAP #Hypertension: Well controlled on HCTZ and amlodipine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. sod phos di, mono-K phos mono [MASKED] mg oral TID 2. Gabapentin 600 mg PO TID 3. Lenalidomide 10 mg po EVERY [MASKED] 4. Metoprolol Succinate XL 25 mg PO DAILY 5. colestipol 1 gram oral BID 6. amLODIPine 10 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. rOPINIRole 0.5 mg PO QAM 9. rOPINIRole 0.25 mg PO QPM 10. ValACYclovir 1000 mg PO Q24H 11. Clopidogrel 75 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. PARoxetine 40 mg PO DAILY 15. Hydrochlorothiazide 12.5 mg PO DAILY 16. Cyanocobalamin 500 mcg PO DAILY 17. FoLIC Acid 1 mg PO DAILY 18. Pyridoxine 50 mg PO DAILY 19. Vitamin D [MASKED] UNIT PO 1X/WEEK (MO) 20. Furosemide 40 mg PO DAILY:PRN weight gain 21. Pregabalin 50 mg PO TID Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. Furosemide 40 mg PO DAILY weight gain Take every day for now after the TAVR 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. colestipol 1 gram oral BID 8. Cyanocobalamin 500 mcg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 600 mg PO TID 11. Hydrochlorothiazide 12.5 mg PO DAILY 12. Lenalidomide 10 mg po EVERY [MASKED] 13. Metoprolol Succinate XL 25 mg PO DAILY 14. PARoxetine 40 mg PO DAILY 15. Pregabalin 50 mg PO TID 16. Pyridoxine 50 mg PO DAILY 17. rOPINIRole 0.25 mg PO QPM 18. rOPINIRole 0.5 mg PO QAM 19. sod phos di, mono-K phos mono [MASKED] mg oral TID 20. ValACYclovir 1000 mg PO Q24H 21. Vitamin D [MASKED] UNIT PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: Severe AS s/p TAVR HTN CAD Embolic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (TAVR) to treat your aortic valve stenosis which was done on [MASKED]. By repairing the valve your heart can pump blood more easily and your chest pain should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking Aspirin and Clopidogrel (Plavix). These medications help to prevent blood clots from forming on the new valve. If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 252 pounds. We may have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call [MASKED]. 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] Heart Line 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]
[]
[ "I5032", "I2510", "I110", "Z955", "F329", "G4733", "E669", "K219" ]
[ "I350: Nonrheumatic aortic (valve) stenosis", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "I5032: Chronic diastolic (congestive) heart failure", "C9000: Multiple myeloma not having achieved remission", "Z6841: Body mass index [BMI]40.0-44.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z23: Encounter for immunization", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I110: Hypertensive heart disease with heart failure", "Z955: Presence of coronary angioplasty implant and graft", "F329: Major depressive disorder, single episode, unspecified", "G629: Polyneuropathy, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,057,482
25,331,549
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: sulfa drugs / Coumadin / lisinopril / Celebrex Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============== ___ 01:13AM BLOOD WBC-8.2 RBC-2.55* Hgb-7.2* Hct-23.5* MCV-92 MCH-28.2 MCHC-30.6* RDW-14.6 RDWSD-49.2* Plt ___ ___ 04:48AM BLOOD Neuts-63.5 Lymphs-18.7* Monos-10.8 Eos-5.8 Baso-0.6 Im ___ AbsNeut-4.49 AbsLymp-1.32 AbsMono-0.76 AbsEos-0.41 AbsBaso-0.04 ___ 01:13AM BLOOD ___ PTT-38.7* ___ ___ 01:13AM BLOOD Glucose-122* UreaN-23* Creat-0.9 Na-137 K-3.7 Cl-97 HCO3-25 AnGap-15 ___ 01:13AM BLOOD ALT-6 AST-14 AlkPhos-73 TotBili-0.2 ___ 01:13AM BLOOD Albumin-3.0* Calcium-7.9* Phos-3.9 Mg-2.0 ___ 01:13AM BLOOD CRP-119.3* ___ 01:13AM BLOOD Vanco-22.1* ___ 01:37AM BLOOD ___ Temp-36.6 pO2-32* pCO2-39 pH-7.47* calTCO2-29 Base XS-4 REPORTS ======= CXR ___: Lungs are low volume with stable small left pleural effusion with left a slow atelectasis. The ET tube projects approximately 4 cm from the carina. There is minimal subsegmental atelectasis in the right lung base. Cardiomediastinal silhouette is stable. Lines and tubes overlying the chest limiting evaluation. No pneumothorax. Right-sided PICC line is unchanged. MR ___ spine ___: 1. Heterogenous marrow signal changes along the endplates primarily at L2-L3 and L3-L4 with associated ill-defined enhancement along the right anterolateral margins of the intervertebral discs, right psoas, and right neural foramina predominantly at L3-L4. Findings could be seen in the setting of an early infectious process with phlegmon formation. No drainable collections identified. 2. Levoconvex scoliosis and multilevel degenerative changes of the lumbar spine with mild-to-moderate spinal stenosis at L3-L4 and severe multilevel primarily right-sided neural foraminal narrowing as detailed above. 3. Please note that there is partial lumbarization of the S1 vertebral body. PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects without low back pain: Overall evidence of disk degeneration 91% (decreased T2 signal, height loss, bulge) T2 signal loss 83% Disk height loss 58% Disk protrusion 32% Annular fissure 38% Jarvik, et all. Spine ___ 26(10):1158-1166 Lumbar spinal stenosis prevalence- present in approximately 20% of asymptomatic adults over ___ years old ___, et al, Spine Journal ___ 9 (7):545-550 These findings are so common in asymptomatic persons that they must be interpreted with caution and in context of the clinical situation. Tagged white scan re-read from ___, study performed ___: IMPRESSION: Suggestion of increased radiotracer uptake projecting over the anterior mediastinum, which is more conspicuous on delayed images and of indeterminate clinical significance. TTE ___: IMPRESSION: No valvular vegetations seen. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mild calcific aortic stenosis. Mild to moderate aortic regurgitation. At least mild mitral regurgiation. Mild pulmonary hypertension. Compared with the prior TTE ___, there has been interim replacement of the ascending aorta. Aortic regurgitation is slightly more prominent now. The other findings are similar. ___ CXR There has been interval extubation. Right PICC is in unchanged position terminating in the distal SVC. Low lung volumes with unchanged left retro and para cardiac opacities and mild vascular congestion without overt pulmonary edema. No pleural effusions. Heart and mediastinum are stable. Substantial calcifications of the mitral annulus are Re demonstrated. IMPRESSION: Interval extubation with persistent, unchanged low lung volumes with mild vascular congestion without frank pulmonary edema. Stable appearance of left retro and para cardiac opacities and substantial mitral valve calcifications. ___ Non-Contrast Head CT The study is extremely limited secondary to motion artifact. The sensitivity of the study is very low for evaluation of recent infarctions or small amounts of hemorrhage. Within the confines of this motion limited study, there is no evidence of fracture, acute infarction,hemorrhage,edema,or mass. There is encephalomalacia in the left frontal lobe, consistent with prior infarct. There is redemonstration of hypodensities within the bilateral basal ganglia and thalami consistent with old infarcts. There is prominence of the ventricles and sulci suggestive of atrophy. The visualized portion of the paranasal sinuses, and middle ear cavities are clear. The bilateral mastoids are opacified. Metallic density is noted within the right external auditory canal and may represent a hearing aid. The visualized portion of the orbits are normal, however the patient is status post bilateral lens replacement. IMPRESSION: 1. Study is very limited for the evaluation of recent infarction secondary to motion. No acute infarct, hemorrhage or mass. 2. Within the limits of this motion limited study, there is no evidence of acute or recent infarct, hemorrhage or mass. DISCHARGE LABS ============== ___ 06:33AM BLOOD WBC-8.6 RBC-2.85* Hgb-8.1* Hct-26.5* MCV-93 MCH-28.4 MCHC-30.6* RDW-15.4 RDWSD-52.6* Plt ___ ___ 09:25AM BLOOD ___ PTT-33.9 ___ ___ 06:33AM BLOOD Glucose-110* UreaN-22* Creat-0.6 Na-140 K-4.0 Cl-93* HCO3-37* AnGap-10 ___ 06:33AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.___ female with past medical history of amyloid angiopathy, atrial fibrillation, CVA, hypertension, OA, Sjogren's syndrome and aortic aneurysm s/p repair (___) who presents as a transfer from ___ with MRSA bacteremia and concern for infected aortic graft who was ultimately felt not to be a surgical candidate and was treated with IV antibiotics, course complicated by persistent issues with secretions managed by humified O2 and nebulizers. She also had persistent altered mental status for which neurology was consulted and she had an EEG without elliptiform discharges even off of Keppra and so her altered mental status was attributed to delirium in the setting of recent ICU stay/intubation and ongoing infection. TRANSITIONAL ISSUES =================== Discharge weight: 120 lb Discharge Cr: 0.6 [] Patient was maintained on vancomycin for MRSA blood stream infection with plan for at least a six week course (___) with full course and oral suppression therapy life long after follow with the infectious disease team at ___. [] For antibiotic therapy monitoring, please obtain: ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough ADDITIONAL ORDERS: *PLEASE OBTAIN WEEKLY CRP for patients with bone/joint infections and endocarditis or endovascular infections [] Patient has had problems with mucous secretions secondary to mouth breathing. Please provide humidified oxygen and saline nebulizers as needed. [] Patient is discharged as strict NPO, all meds through G tube, please consider repeat speech and swallow evaluation as mental status improves. [] Patient was started on torsemide 10MG daily this admission. Please recheck BMP in one week (on ___ to ensure stable electrolytes and kidney function, and adjust direutic dosing as needed based on volume status. [] Metoprolol increased to 12.5MG Q6H this admission, continue to monitor HR and adjust as needed, goal HR < 110 ___CUTE ISSUES ============ #MRSA bacteremia #?aortic aneurysm graft infection Per OSH records growing MRSA on admission cultures with last positive cultures reportedly ___. OSH ID highly concerned for graft infection given tagged WBC study. Imaging reviewed by our radiologists and found to be inconclusive. MRI imaging of lower spine shows lumbar phlegmon. Cases reviewed by cardiac and neurosurgical services. Not a candidate for surgery given medical comorbidities. Additional diagnostic testing TEE, Lumbar spine phlegmon sampling with ___ were extensively discussed. Given that the patient would require long term antibiotics and these invasive tests would not change management as the patient was not a surgical candidate this testing was not pursued. Patient was treated with vancomycin with plan for at least 6 week course with planned OPAT follow up for final course and transition to lifelong oral suppression. # Toxic metabolic encephalopathy # Delirium She is waxing and waning and at times is able to answer questions while at other times is sleepy and only picking at things. Delirium likely caused by her multiple prior infarcts, and she is easily tipped over with any insult - in this case likely her bacteremia and infectious state. Repeat Non-contrast CT head- without new any interracial process. TSH mild elevated at 5.2, Normal B12/Folate and negative Syphilis. Consulted neurology to assess for possible subclinical seizures. Underwent video EEG monitoring, no epileptiform activity noted and so Keppra was stopped on discharge, encephalopathy likely secondary infections and ICU delirum. #Hypoxemic respiratory failure Multifactorial in setting of HAP and acute on chronic HFpEF exacerbation at previous hospital. Complex course there but notable for extubated ___ after successful SBT, unfortunately reintubated due to wheezing and respiratory distress. In ___ ICU patient respiratory status initially limited by tracheal wall edema with loss of cuff leak though steroids deferred with self resolution. Concern for high risk extubation given prior failure, prior trach. Family meeting held and family determined would want re-intubation which would likely require trach/peg. Patient extubated successfully on ___ and had ongoing problems with secretions which were managed with humidified O2 via face tent guaifenesin, and oral care. #Acute on chronic HFpEF exacerbation Per records grossly volume overloaded on presentation, had been undergoing diuresis with 40 IV Lasix TID at OSH. On initial exam appeared euvolemic at BI with targeted fluid balance net even. Patient received intermittent doses of 60mg IV Lasix for diuresis and transitioned to Torsemide 10mg. #?L2-L3 discitis with phlegmon Noted on OSH on CT lumbar spine obtained due to back pain. Would not be inconceivable given virulence of MRSA. No neurosurgical intervention as there is no epidural collection or spinal canal involvement per spine consult. Managed with antibiotics and antibiotics as above. #pAfib CHADSVASC at least 6, therapeutic on warfarin. Increased home Metoprolol Tartrate to 12.5 mg PO/NG Q6H and daily dosed warfarin. INR at discharge 1.7, so she was given an increased dose day of discharge. CHRONIC ISSUES ============== #Chronic pain - Continued duloxetine, gabapentin #Seizure disorder - Stopped keppra as above after normal EEG off Keppra #Hypothyroidism - Continued levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 2. Metoprolol Tartrate 25 mg NG Q8H 3. Warfarin 5 mg NG DAILY16 4. DULoxetine ___ 30 mg PO BID 5. Levothyroxine Sodium 75 mcg NG DAILY 6. Nystatin Oral Suspension 5 mL PO TID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Magnesium Oxide 400 mg NG DAILY 9. Gabapentin 100 mg NG BID 10. Gabapentin 200 mg NG QHS 11. Pravastatin 20 mg PO QHS 12. Modafinil 200 mg NG DAILY 13. Ascorbic Acid ___ mg NG BID 14. Thiamine 100 mg NG DAILY 15. Zinc Sulfate 220 mg NG DAILY 16. LevETIRAcetam Oral Solution 500 mg NG BID 17. Cyanocobalamin 1000 mcg NG DAILY 18. Vancomycin 1000 mg IV Q 24H 19. Piperacillin-Tazobactam 3.375 g IV Q8H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 3. Atorvastatin 80 mg PO QPM 4. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain 5. GuaiFENesin ER 600 mg PO Q12H 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 7. Torsemide 10 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Metoprolol Tartrate 12.5 mg PO Q6H 10. Vancomycin 750 mg IV Q 24H 11. Ascorbic Acid ___ mg NG BID 12. Cyanocobalamin 1000 mcg NG DAILY 13. DULoxetine ___ 30 mg PO BID 14. Levothyroxine Sodium 75 mcg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. Magnesium Oxide 400 mg NG DAILY 17. Modafinil 200 mg NG DAILY 18. Nystatin Oral Suspension 5 mL PO TID 19. Thiamine 100 mg NG DAILY 20. Warfarin 5 mg PO DAILY16 21. Zinc Sulfate 220 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY ======= MRSA Bacteremia Toxic Metabolic Encephalopathy SECONDARY ========= Amyloid Angiopathy Atrial Fibrillation Hypertension Sjogren's syndrome Abdominal Aortic Dissection s/p emergent type A aortic dissection with repair ___ Anemia of Chronic Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were having trouble breathing and had an infection in your blood stream. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were treated with breathing treatments, antibiotics for possible pneumonia, and medications to remove fluid from your lungs with improvement in your breathing. - You were continued on IV antibiotics for your blood stream infection. You should continue on these for long term and follow up with the infectious disease team WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
[ "T827XXA", "G92", "I5033", "J151", "J9621", "I69354", "E854", "I110", "E039", "D638", "G8929", "M3500", "G629", "M1990", "Z7901", "Z8679", "Z8674", "M4646", "L98429", "Z781", "I680", "I480", "G40909", "Y832", "Y929", "J9809" ]
Allergies: sulfa drugs / Coumadin / lisinopril / Celebrex Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============== [MASKED] 01:13AM BLOOD WBC-8.2 RBC-2.55* Hgb-7.2* Hct-23.5* MCV-92 MCH-28.2 MCHC-30.6* RDW-14.6 RDWSD-49.2* Plt [MASKED] [MASKED] 04:48AM BLOOD Neuts-63.5 Lymphs-18.7* Monos-10.8 Eos-5.8 Baso-0.6 Im [MASKED] AbsNeut-4.49 AbsLymp-1.32 AbsMono-0.76 AbsEos-0.41 AbsBaso-0.04 [MASKED] 01:13AM BLOOD [MASKED] PTT-38.7* [MASKED] [MASKED] 01:13AM BLOOD Glucose-122* UreaN-23* Creat-0.9 Na-137 K-3.7 Cl-97 HCO3-25 AnGap-15 [MASKED] 01:13AM BLOOD ALT-6 AST-14 AlkPhos-73 TotBili-0.2 [MASKED] 01:13AM BLOOD Albumin-3.0* Calcium-7.9* Phos-3.9 Mg-2.0 [MASKED] 01:13AM BLOOD CRP-119.3* [MASKED] 01:13AM BLOOD Vanco-22.1* [MASKED] 01:37AM BLOOD [MASKED] Temp-36.6 pO2-32* pCO2-39 pH-7.47* calTCO2-29 Base XS-4 REPORTS ======= CXR [MASKED]: Lungs are low volume with stable small left pleural effusion with left a slow atelectasis. The ET tube projects approximately 4 cm from the carina. There is minimal subsegmental atelectasis in the right lung base. Cardiomediastinal silhouette is stable. Lines and tubes overlying the chest limiting evaluation. No pneumothorax. Right-sided PICC line is unchanged. MR [MASKED] spine [MASKED]: 1. Heterogenous marrow signal changes along the endplates primarily at L2-L3 and L3-L4 with associated ill-defined enhancement along the right anterolateral margins of the intervertebral discs, right psoas, and right neural foramina predominantly at L3-L4. Findings could be seen in the setting of an early infectious process with phlegmon formation. No drainable collections identified. 2. Levoconvex scoliosis and multilevel degenerative changes of the lumbar spine with mild-to-moderate spinal stenosis at L3-L4 and severe multilevel primarily right-sided neural foraminal narrowing as detailed above. 3. Please note that there is partial lumbarization of the S1 vertebral body. PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects without low back pain: Overall evidence of disk degeneration 91% (decreased T2 signal, height loss, bulge) T2 signal loss 83% Disk height loss 58% Disk protrusion 32% Annular fissure 38% Jarvik, et all. Spine [MASKED] 26(10):1158-1166 Lumbar spinal stenosis prevalence- present in approximately 20% of asymptomatic adults over [MASKED] years old [MASKED], et al, Spine Journal [MASKED] 9 (7):545-550 These findings are so common in asymptomatic persons that they must be interpreted with caution and in context of the clinical situation. Tagged white scan re-read from [MASKED], study performed [MASKED]: IMPRESSION: Suggestion of increased radiotracer uptake projecting over the anterior mediastinum, which is more conspicuous on delayed images and of indeterminate clinical significance. TTE [MASKED]: IMPRESSION: No valvular vegetations seen. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mild calcific aortic stenosis. Mild to moderate aortic regurgitation. At least mild mitral regurgiation. Mild pulmonary hypertension. Compared with the prior TTE [MASKED], there has been interim replacement of the ascending aorta. Aortic regurgitation is slightly more prominent now. The other findings are similar. [MASKED] CXR There has been interval extubation. Right PICC is in unchanged position terminating in the distal SVC. Low lung volumes with unchanged left retro and para cardiac opacities and mild vascular congestion without overt pulmonary edema. No pleural effusions. Heart and mediastinum are stable. Substantial calcifications of the mitral annulus are Re demonstrated. IMPRESSION: Interval extubation with persistent, unchanged low lung volumes with mild vascular congestion without frank pulmonary edema. Stable appearance of left retro and para cardiac opacities and substantial mitral valve calcifications. [MASKED] Non-Contrast Head CT The study is extremely limited secondary to motion artifact. The sensitivity of the study is very low for evaluation of recent infarctions or small amounts of hemorrhage. Within the confines of this motion limited study, there is no evidence of fracture, acute infarction,hemorrhage,edema,or mass. There is encephalomalacia in the left frontal lobe, consistent with prior infarct. There is redemonstration of hypodensities within the bilateral basal ganglia and thalami consistent with old infarcts. There is prominence of the ventricles and sulci suggestive of atrophy. The visualized portion of the paranasal sinuses, and middle ear cavities are clear. The bilateral mastoids are opacified. Metallic density is noted within the right external auditory canal and may represent a hearing aid. The visualized portion of the orbits are normal, however the patient is status post bilateral lens replacement. IMPRESSION: 1. Study is very limited for the evaluation of recent infarction secondary to motion. No acute infarct, hemorrhage or mass. 2. Within the limits of this motion limited study, there is no evidence of acute or recent infarct, hemorrhage or mass. DISCHARGE LABS ============== [MASKED] 06:33AM BLOOD WBC-8.6 RBC-2.85* Hgb-8.1* Hct-26.5* MCV-93 MCH-28.4 MCHC-30.6* RDW-15.4 RDWSD-52.6* Plt [MASKED] [MASKED] 09:25AM BLOOD [MASKED] PTT-33.9 [MASKED] [MASKED] 06:33AM BLOOD Glucose-110* UreaN-22* Creat-0.6 Na-140 K-4.0 Cl-93* HCO3-37* AnGap-10 [MASKED] 06:33AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.[MASKED] female with past medical history of amyloid angiopathy, atrial fibrillation, CVA, hypertension, OA, Sjogren's syndrome and aortic aneurysm s/p repair ([MASKED]) who presents as a transfer from [MASKED] with MRSA bacteremia and concern for infected aortic graft who was ultimately felt not to be a surgical candidate and was treated with IV antibiotics, course complicated by persistent issues with secretions managed by humified O2 and nebulizers. She also had persistent altered mental status for which neurology was consulted and she had an EEG without elliptiform discharges even off of Keppra and so her altered mental status was attributed to delirium in the setting of recent ICU stay/intubation and ongoing infection. TRANSITIONAL ISSUES =================== Discharge weight: 120 lb Discharge Cr: 0.6 [] Patient was maintained on vancomycin for MRSA blood stream infection with plan for at least a six week course ([MASKED]) with full course and oral suppression therapy life long after follow with the infectious disease team at [MASKED]. [] For antibiotic therapy monitoring, please obtain: ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough ADDITIONAL ORDERS: *PLEASE OBTAIN WEEKLY CRP for patients with bone/joint infections and endocarditis or endovascular infections [] Patient has had problems with mucous secretions secondary to mouth breathing. Please provide humidified oxygen and saline nebulizers as needed. [] Patient is discharged as strict NPO, all meds through G tube, please consider repeat speech and swallow evaluation as mental status improves. [] Patient was started on torsemide 10MG daily this admission. Please recheck BMP in one week (on [MASKED] to ensure stable electrolytes and kidney function, and adjust direutic dosing as needed based on volume status. [] Metoprolol increased to 12.5MG Q6H this admission, continue to monitor HR and adjust as needed, goal HR < 110 CUTE ISSUES ============ #MRSA bacteremia #?aortic aneurysm graft infection Per OSH records growing MRSA on admission cultures with last positive cultures reportedly [MASKED]. OSH ID highly concerned for graft infection given tagged WBC study. Imaging reviewed by our radiologists and found to be inconclusive. MRI imaging of lower spine shows lumbar phlegmon. Cases reviewed by cardiac and neurosurgical services. Not a candidate for surgery given medical comorbidities. Additional diagnostic testing TEE, Lumbar spine phlegmon sampling with [MASKED] were extensively discussed. Given that the patient would require long term antibiotics and these invasive tests would not change management as the patient was not a surgical candidate this testing was not pursued. Patient was treated with vancomycin with plan for at least 6 week course with planned OPAT follow up for final course and transition to lifelong oral suppression. # Toxic metabolic encephalopathy # Delirium She is waxing and waning and at times is able to answer questions while at other times is sleepy and only picking at things. Delirium likely caused by her multiple prior infarcts, and she is easily tipped over with any insult - in this case likely her bacteremia and infectious state. Repeat Non-contrast CT head- without new any interracial process. TSH mild elevated at 5.2, Normal B12/Folate and negative Syphilis. Consulted neurology to assess for possible subclinical seizures. Underwent video EEG monitoring, no epileptiform activity noted and so Keppra was stopped on discharge, encephalopathy likely secondary infections and ICU delirum. #Hypoxemic respiratory failure Multifactorial in setting of HAP and acute on chronic HFpEF exacerbation at previous hospital. Complex course there but notable for extubated [MASKED] after successful SBT, unfortunately reintubated due to wheezing and respiratory distress. In [MASKED] ICU patient respiratory status initially limited by tracheal wall edema with loss of cuff leak though steroids deferred with self resolution. Concern for high risk extubation given prior failure, prior trach. Family meeting held and family determined would want re-intubation which would likely require trach/peg. Patient extubated successfully on [MASKED] and had ongoing problems with secretions which were managed with humidified O2 via face tent guaifenesin, and oral care. #Acute on chronic HFpEF exacerbation Per records grossly volume overloaded on presentation, had been undergoing diuresis with 40 IV Lasix TID at OSH. On initial exam appeared euvolemic at BI with targeted fluid balance net even. Patient received intermittent doses of 60mg IV Lasix for diuresis and transitioned to Torsemide 10mg. #?L2-L3 discitis with phlegmon Noted on OSH on CT lumbar spine obtained due to back pain. Would not be inconceivable given virulence of MRSA. No neurosurgical intervention as there is no epidural collection or spinal canal involvement per spine consult. Managed with antibiotics and antibiotics as above. #pAfib CHADSVASC at least 6, therapeutic on warfarin. Increased home Metoprolol Tartrate to 12.5 mg PO/NG Q6H and daily dosed warfarin. INR at discharge 1.7, so she was given an increased dose day of discharge. CHRONIC ISSUES ============== #Chronic pain - Continued duloxetine, gabapentin #Seizure disorder - Stopped keppra as above after normal EEG off Keppra #Hypothyroidism - Continued levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 2. Metoprolol Tartrate 25 mg NG Q8H 3. Warfarin 5 mg NG DAILY16 4. DULoxetine [MASKED] 30 mg PO BID 5. Levothyroxine Sodium 75 mcg NG DAILY 6. Nystatin Oral Suspension 5 mL PO TID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Magnesium Oxide 400 mg NG DAILY 9. Gabapentin 100 mg NG BID 10. Gabapentin 200 mg NG QHS 11. Pravastatin 20 mg PO QHS 12. Modafinil 200 mg NG DAILY 13. Ascorbic Acid [MASKED] mg NG BID 14. Thiamine 100 mg NG DAILY 15. Zinc Sulfate 220 mg NG DAILY 16. LevETIRAcetam Oral Solution 500 mg NG BID 17. Cyanocobalamin 1000 mcg NG DAILY 18. Vancomycin 1000 mg IV Q 24H 19. Piperacillin-Tazobactam 3.375 g IV Q8H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 3. Atorvastatin 80 mg PO QPM 4. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain 5. GuaiFENesin ER 600 mg PO Q12H 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 7. Torsemide 10 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Metoprolol Tartrate 12.5 mg PO Q6H 10. Vancomycin 750 mg IV Q 24H 11. Ascorbic Acid [MASKED] mg NG BID 12. Cyanocobalamin 1000 mcg NG DAILY 13. DULoxetine [MASKED] 30 mg PO BID 14. Levothyroxine Sodium 75 mcg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. Magnesium Oxide 400 mg NG DAILY 17. Modafinil 200 mg NG DAILY 18. Nystatin Oral Suspension 5 mL PO TID 19. Thiamine 100 mg NG DAILY 20. Warfarin 5 mg PO DAILY16 21. Zinc Sulfate 220 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY ======= MRSA Bacteremia Toxic Metabolic Encephalopathy SECONDARY ========= Amyloid Angiopathy Atrial Fibrillation Hypertension Sjogren's syndrome Abdominal Aortic Dissection s/p emergent type A aortic dissection with repair [MASKED] Anemia of Chronic Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were having trouble breathing and had an infection in your blood stream. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were treated with breathing treatments, antibiotics for possible pneumonia, and medications to remove fluid from your lungs with improvement in your breathing. - You were continued on IV antibiotics for your blood stream infection. You should continue on these for long term and follow up with the infectious disease team WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[ "I110", "E039", "G8929", "Z7901", "I480", "Y929" ]
[ "T827XXA: Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter", "G92: Toxic encephalopathy", "I5033: Acute on chronic diastolic (congestive) heart failure", "J151: Pneumonia due to Pseudomonas", "J9621: Acute and chronic respiratory failure with hypoxia", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "E854: Organ-limited amyloidosis", "I110: Hypertensive heart disease with heart failure", "E039: Hypothyroidism, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "G8929: Other chronic pain", "M3500: Sicca syndrome, unspecified", "G629: Polyneuropathy, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z7901: Long term (current) use of anticoagulants", "Z8679: Personal history of other diseases of the circulatory system", "Z8674: Personal history of sudden cardiac arrest", "M4646: Discitis, unspecified, lumbar region", "L98429: Non-pressure chronic ulcer of back with unspecified severity", "Z781: Physical restraint status", "I680: Cerebral amyloid angiopathy", "I480: Paroxysmal atrial fibrillation", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "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", "J9809: Other diseases of bronchus, not elsewhere classified" ]
10,057,482
25,416,257
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: sulfa drugs / Coumadin / lisinopril / Celebrex Attending: ___ Chief Complaint: Fatigue, weakness, dyspnea on exertion Major Surgical or Invasive Procedure: ___: Emergent Right femoral cannulation, Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch. Repair of small liver laceration. ___: Chest re-exploration and washout, sternal closure ___: Percutaneous tracheostomy (8 cuffed tracheostomy), percutaneous endoscopic gastrostomy tube (___) ___: RUE PICC placement (Hub Rt. ___. 40 cm. DLumen) History of Present Illness: Ms. ___ is an ___ year old woman with a history of amyloid angiopathy, atrial fibrillation, cerebrovascular accident, hypertension, osteoarthritis, and Sjogren's syndrome. She presented to ___ with back pain radiating to her left arm and jaw. She underwent a CTA of the chest and abdomen. The visualized portion of the ascending thoracic aorta is dilated measuring up to 6.3 cm. An intimal flap is also seen at the visualized portion of the ascending thoracic aorta. Great vessels are not evaluated. She was transferred to ___ for surgical intervention. Past Medical History: Amyloid Angiopathy Atrial Fibrillation Cerebrovascular Accident with left sided weakness/pronator drift Chronic Back Pain Hyperlipidemia Hypertension Osteoarthritis Peripheral Neuropathy Rheumatic Fever Sjogrens Syndrome PSH: Breast biopsy x 2 (negative) Ex-lap for SBO Lumbar surgery ___ Social History: ___ Family History: Mother - died ___ ? cause Father - died ___ with skin ca and ___ stroke Sibs - 1 brother ___ on dialyssi for renal failure, sister age ___ Children - 2 sons with T1dm and 1 daughter with T2DM and has had some seizures There is no history of developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, dementia or movement disorders. Physical Exam: Admission Exam: BP: 74/40, HR 100 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 [x] ___none__ Varicosities: None [x] Neuro: Left sided upper and lower extremity weakness Pulses: DP Right: 2+ Left: 2+ ___ Right: 2+ Left: 2+ Radial Right: 1+ Left: 1+ Discharge Exam: 110/49 79SR 16 95% trach collar . General: NAD [x] Neurological: Moves all extremities spontaneously[x] Chemically paralyzed [] sedated [] Follows commands: weak L hand grasp and bilat toe wiggle/extension [x] HEENT: PEERL [x] MMM[x] Cardiovascular: RRR [x] Irregular [] Murmur, II/VI upper LSB [x] Respiratory: Clear but decreased L>R [x] No resp distress [x] Intubated [] trach site c/d/I [x] increased secretions [x] GU/Renal: Urine clear [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] mild tenderness w/deep palp LUQ [x] flexiseal ___ place [x] PEG c/d/i-no erythema [x] Extremities: Right Upper extremity Warm [x] Edema tr Left Upper extremity Warm [x] Edema tr Right Lower extremity Warm [x] Edema tr Left Lower extremity Warm [x] Edema tr Pulses: DP Right:1 Left:1 ___ Right:1 Left:1 Radial Right:1 Left:Aline ___ place Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] R SC TLC: c/d/I [x] Pertinent Results: STUDIES: PA/LAT CXR ___ (Preliminary): RUE PICC line placed with tip ___ mid SVC. PA/LAT CXR ___ ___ comparison with the study ___, the monitoring support devices are unchanged, as is the left pleural effusion with compressive basilar atelectasis and enlargement of the cardiac silhouette. Indistinctness of pulmonary vessels is consistent with some elevation of pulmonary venous pressure. Chest CTA ___ 1. Type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen, inferior extent not included on the images. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. 2. Small to moderate amount of hemopericardium. Mediastinal blood/hematoma exerts mass-effect with resultant narrowing of the main left and right pulmonary arteries. No active extravasation seen. Transesophageal Echocardiogram ___ PRE-OPERATIVE STATE: Sinus rhythm. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Normal RA size. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Moderate symmetric hypertrophy. Normal cavity size, though the ventricle is significantly underfilled. Normal regional & global systolic function Normal ejection fraction. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: SEVERE ascending dilation. Type A ascending, arch and descending DISSECTION. Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet calcification. Mild (>1.5cm2) stenosis. Mild-moderate [___] regurgitation. Central jet. The dissection flap does not involve the aortic valve. Mitral Valve: Normal leaflets. No stenosis. Moderate annular calcification. Mild [1+] regurgitation. Central jet. Tricuspid Valve: Normal leaflets. Pericardium: Moderate effusion. RA systolic collapse/early tamponade. Miscellaneous: Left pleural effusion. POST-OP STATE: The TEE was performed at 21:00:00. Atrial fibrillation. Support: Vasopressor(s): epinephrine. Left Ventricle: Similar to preoperative findings. Global ejection fraction is normal. LV remains underfilled. Right Ventricle: New/worse global dysfunction. RV function is mildly depressed. Aorta: Aortic tube graft ___ position. Dissection ___ aortic arch and descending aorta unchanged. Aortic Valve: No change ___ aortic valve morphology from preoperative state. No change ___ aortic regurgitation. Mitral Valve: No change ___ mitral valve morphology from preoperative state. No change ___ valvular regurgitation from preoperative state. Pericardium: No effusion. Miscellaneous: No pleural effusions. Notification: The surgeon/proceduralist was notified of the findings at the time of the study. Renal Artery Ultrasound ___ Magnitude of vascularity of the left kidney is lower on the left than on the right, suggesting the left renal artery arises from the false lumen and right renal artery from the true lumen as seen on prior CT imaging. However, it was not possible to directly visualize the renal artery origins sonographically due to poor visualization at this time. Left upper extremity ultrasound ___ 1. Deep vein thrombosis with complete occlusion of flow involving the mid to low left internal jugular vein. 2. No evidence of additional deep vein thrombosis ___ the left upper extremity. MR ___ ___ 1. Numerous, scattered acute or early subacute infarcts, majority of which are punctate, however there is a larger approximately 3.0 cm left frontal area of acute or early subacute infarct. No evidence of hemorrhagic conversion. Chronic lacunar infarcts are also noted. 2. Innumerable areas of susceptibility on gradient echo imaging, compatible with amyloid angiopathy. 3. Moderate paranasal sinus disease, as detailed above, including air-fluid levels, suggestive of acute sinusitis. ___ CT ___ 1. Evolving acute infarct ___ the left frontal lobe. No evidence of hemorrhagic conversion. 2. Additional smaller infarcts ___ the bilateral cerebral hemispheres and cerebellar hemispheres are better appreciated on prior MRI. Chest CT ___ 1. Multifocal bilateral ground-glass, nodular opacities and consolidation ___ both lower lobes, worse on the left are likely secondary to multifocal pneumonia. 2. New small bilateral pleural effusions. 3. Type A aortic dissection incompletely characterized ___ this study, with new hyperdense material at the ascending aorta, likely related to the repair. Atherosclerotic plaque CT outline the true lumen ___ the remainder thoracic aorta which appears not significantly changed ___ caliber from prior. Chest CT ___ 1. Nodular peribronchovascular airspace disease ___ the dependent aspect of the right upper lobe and basal aspects of the right middle and lower lobes most likely represents bronchopneumonia. The overall disease burden is decreased (especially ___ the dependent aspect of the right upper lobe) compared to prior CT studies. 2. Please note that it is difficult to differentiate atelectasis from consolidation on a non contrasted study. However, airspace opacification ___ the dependent aspect of the left upper lobe and superior segment of the left lower lobe most likely represents atelectasis. Ground-glass airspace opacification ___ the left lower lobe is nonspecific. 3. Small left-sided pleural effusion. 4. Patient is status post aortic root repair. Residual post dissection changes are difficult to assess on a noncontrast study. CT Aorta and branches ___ The aorta measures 3.5 cm ___ the proximal portion, 3.5 cm ___ mid portion and 3.4 cm ___ the distal abdominal aorta. There is suboptimal visualization of the mid and distal aorta due to overlying bowel gas, tortuosity of the aorta, and body habitus. The known aortic dissection is re-demonstrated. There is echogenic material within the distal aorta which is consistent with thrombus, however size comparison to prior exam is difficult due to limited sonographic windows. The iliac arteries are not visualized. IMPRESSION: Technically limited assessment of the distal abdominal aorta however intraluminal echogenic material corresponds to the known thrombus, however size comparison is difficult. If further comparison is desired and the patient cannot tolerate a CTA, non-contrast MRI with multiplanar imaging could be performed. MICRO: ___ 1:08 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL. YEAST. ___ CFU/mL. ___ 11:15 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. ___ 8:39 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. >100,000 CFU/mL. ___ 9:41 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ~5000 CFU/mL. ___ 11:30 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. MODERATE GROWTH. ASPERGILLUS FUMIGATUS COMPLEX. SUSCEPTIBILITIES REQUESTED PER ___ ___ (___) ON ___. Refer to sendout/miscellaneous reporting for results. SENT TO ___ ON ___. LABS: Admit: ___ 02:05PM BLOOD WBC-10.7* RBC-3.83* Hgb-10.8* Hct-34.4 MCV-90 MCH-28.2 MCHC-31.4* RDW-14.2 RDWSD-46.2 Plt ___ ___ 02:05PM BLOOD ___ PTT-27.2 ___ ___ 08:15AM BLOOD HIT Ab-NEG HIT ___ ___ 08:15AM BLOOD HIT Ab-NEG HIT ___ ___ 02:05PM BLOOD Glucose-141* UreaN-21* Creat-0.9 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 ___ 03:45AM BLOOD ALT-12 AST-40 LD(LDH)-476* AlkPhos-27* Amylase-23 TotBili-0.7 ___ 03:26PM BLOOD Lipase-1429* ___ 03:45AM BLOOD Albumin-2.5* Calcium-8.7 Phos-3.7 Mg-2.4 ___ 08:15AM BLOOD Triglyc-187* ___ 03:00AM BLOOD Cortsol-20.9* Discharge: ___ 03:04AM BLOOD WBC-10.0 RBC-2.64* Hgb-7.9* Hct-25.6* MCV-97 MCH-29.9 MCHC-30.9* RDW-16.5* RDWSD-56.2* Plt ___ ___ 03:04AM BLOOD ___ PTT-85.3* ___ ___ 12:52AM BLOOD ___ PTT-68.7* ___ ___ 02:06AM BLOOD ___ PTT-66.2* ___ ___ 09:38AM BLOOD ___ PTT-70.2* ___ ___ 02:40AM BLOOD ___ PTT-82.5* ___ ___ 01:37PM BLOOD ___ PTT-76.1* ___ ___ 03:03AM BLOOD ___ PTT-77.7* ___ ___ 03:04AM BLOOD Glucose-126* UreaN-45* Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-24 AnGap-16 ___ 12:52AM BLOOD Glucose-147* UreaN-51* Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-25 AnGap-15 ___ 02:06AM BLOOD ALT-16 AST-24 LD(LDH)-259* AlkPhos-97 Amylase-368* TotBili-0.2 ___ 03:08AM BLOOD ALT-8 AST-19 LD(LDH)-390* AlkPhos-69 Amylase-716* TotBili-0.6 ___ 02:06AM BLOOD Lipase-403* ___ 02:58PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.8 Brief Hospital Course: She was admitted emergently on ___. A CTA of the chest confirmed a type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. She was taken to the operating room and under went Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch and repair of small liver laceration. Please see operative note for full details. She tolerated the procedure and was transferred to the CVICU on multiple pressors and inotropes and paralytics with an open sternotomy for recovery and invasive monitoring. She was volume overloaded on arrival and was started on a Lasix infusion for aggressive diuresis. She returned to the OR for chest closure on ___. She was weaned off of paralytics and sedation. The patient remained lethargic and given her prior history of CVA neurology was consulted. An MRI was obtained which revealed a frontal CVA. A follow up ___ CT showed no evidence of hemorrhagic conversion. Given her embolic CVA, evidence of left IJ thrombus on ultrasound and clot seen on CTA ___ the abdominal aorta, she was started on heparin. The patient's mental status continued to wax and wane and she had persistent encephalopathy and weakness. On ___ an EEG showed discharges consistent with early seizure activity. She was loaded with Keppra. A repeat CT did not show evidence of further CVA. The patient developed fevers and cultures were sent. A chest CT showed evidence of PNA and she had continued difficulty weaning from the ventilator. She was started on empiric Vanco/Cefepime which was then narrowed to an empiric course of cefepime per the ID team. She grew Aspergillus from sputum cultures and the decision was made to treat this with Voriconazole then changed to Isavuconazole due to a prolonged QTc. Cefepime was stopped due to her seizure activity. She was extubated on ___ however she became acutely short of breath and was reintubated. Given her other comorbities the decision was made to proceed with Trach/PEG on ___. She gradually continued with trach collar trials. She has a history of atrial fibrillation and developed intermittent atrial fibrillation that was treated with Lopressor, Amiodarone was held due to prolonged QTc. During this prolonged ICU stay she also developed ___. Nephrolgy was also consulted, her diuretics were limited and she was started on free water flushes via PEG. Slowly her renal function trended back to her baseline levels. She continues to receive free water flushes for hypernatremia. She continues to be encephalopathic but this has been improving slowly, she is responsive and follows some simple commands. She has been tolerating progressively longer periods of time on trach collar (daytime trials began ___ and she began 24h ATC TC ___. She is ___ sinus rhythm and has not had any post-op Afib for several weeks. Her anticoagulation is for afib/DVT and aortic thrombus, continues on heparin bridging and slowly being converted to Coumadin. Goal INR is ___, goal PTT is 50-70. She is tolerating her tube feeds, did have elevated pancreatic enzymes initially. These trended down when she was placed on elemental tube feeds and have continued to trend down for the past 2 weeks. She had yeast ___ both BAL and urine and was started on antifungals (Isavuconazole), this therapy will continue for 6 weeks from start date of ___ with end date ___ and she requires weekly CBC/LFTs per ID recs. Regarding her Keppra and Coumadin duration, these will be reviewed by her neurologist Dr. ___ at a 1 month ___ clinic visit with CTA Torso. She will also need 1 month clinic visit with Vascular team. On, ___ LUE PICC was attempted but could not thread wire and then successfully placed RUE PICC. CXR at that time showed L collapse, so recruitment maneuver done and placed back on PEEP 10. Speech recommdation is that she will likely need trach downsize prior to tolerance of PMV. She was discharged POD 34 to ___ ___ ___ with follow up instructions. Medications on Admission: 1. Diltiazem Extended-Release 180 mg PO Q12H 2. Gabapentin 300 mg PO BID 3. Gabapentin 600 mg PO QHS 4. amLODIPine 1.25 mg PO DAILY 5. Simvastatin 10 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 4. Artificial Tears GEL 1% 1 DROP BOTH EYES Q4H 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 8. Glucose Gel 15 g PO PRN hypoglycemia protocol 9. HydrALAZINE 10 mg IV Q6H:PRN HTN 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 12. Isavuconazonium Sulfate 372 mg PO DAILY Aspergillus PNA Duration: 6 Weeks start date ___ expected finish date ___ 13. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 14. LevETIRAcetam 500 mg PO Q12H 15. Metoprolol Tartrate 25 mg PO TID Hold for HR<60,SBP<90 16. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash 17. Nystatin Oral Suspension 5 mL PO TID 18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 19. Ramelteon 8 mg PO QHS:PRN insomnia 20. Senna 8.6 mg PO BID:PRN Constipation - First Line 21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 22. ___ MD to order daily dose PO DAILY16 23. Warfarin 5 mg PO ONCE Duration: 1 Dose (h/o: postop Afib, aortic thrombus and LIJ DVT) goal INR ___ 24. Simvastatin 10 mg PO QPM 25. HELD- Aspirin 325 mg PO DAILY This medication was held. Do not restart Aspirin until cleared by neurology (Dr. ___ 26. HELD- Diltiazem Extended-Release 180 mg PO Q12H This medication was held. Do not restart Diltiazem Extended-Release until you see cardiologist Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Type A Aortic Dissection s/p ascending aortic replacement Hosp acquired pneumonia/Resp failure s/p trach & PEG placement Acute kidney injury CVA-left frontal infarct w/associated seizure activity postop Atrial Fibrillation Deep Vein Thrombosis Liver Laceration Hypernatremia Aspergillus Pneumonia elevated Pancreatic enzymes Secondary: PMH: CVA(left sided weakness/pronator drift), Sjogrens syndrome, HLD, HTN, peripheral neuropathy. PSH: Ex-lap for SBO, Lumbar surgery ___, breast biopsyx2 (negative) Discharge Condition: Neuro: opens eyes to voice, moves UE spontaneously, lightly squeezes both hands Full care and lift Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace PICC RUE- c/d/i Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then ___ the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___
[ "I7101", "I6340", "J9601", "T8111XA", "J690", "N170", "I314", "J95851", "I69954", "I82C12", "G9340", "B441", "D62", "I313", "J90", "K9172", "E873", "I7409", "E870", "J9819", "E854", "I97190", "G629", "M3500", "E8770", "R569", "D696", "I4581", "E8351", "I480", "I10", "I680", "M1990", "Y92234", "Y831", "M549", "R948", "E8339", "Y848" ]
Allergies: sulfa drugs / Coumadin / lisinopril / Celebrex Chief Complaint: Fatigue, weakness, dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED]: Emergent Right femoral cannulation, Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch. Repair of small liver laceration. [MASKED]: Chest re-exploration and washout, sternal closure [MASKED]: Percutaneous tracheostomy (8 cuffed tracheostomy), percutaneous endoscopic gastrostomy tube ([MASKED]) [MASKED]: RUE PICC placement (Hub Rt. [MASKED]. 40 cm. DLumen) History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with a history of amyloid angiopathy, atrial fibrillation, cerebrovascular accident, hypertension, osteoarthritis, and Sjogren's syndrome. She presented to [MASKED] with back pain radiating to her left arm and jaw. She underwent a CTA of the chest and abdomen. The visualized portion of the ascending thoracic aorta is dilated measuring up to 6.3 cm. An intimal flap is also seen at the visualized portion of the ascending thoracic aorta. Great vessels are not evaluated. She was transferred to [MASKED] for surgical intervention. Past Medical History: Amyloid Angiopathy Atrial Fibrillation Cerebrovascular Accident with left sided weakness/pronator drift Chronic Back Pain Hyperlipidemia Hypertension Osteoarthritis Peripheral Neuropathy Rheumatic Fever Sjogrens Syndrome PSH: Breast biopsy x 2 (negative) Ex-lap for SBO Lumbar surgery [MASKED] Social History: [MASKED] Family History: Mother - died [MASKED] ? cause Father - died [MASKED] with skin ca and [MASKED] stroke Sibs - 1 brother [MASKED] on dialyssi for renal failure, sister age [MASKED] Children - 2 sons with T1dm and 1 daughter with T2DM and has had some seizures There is no history of developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, dementia or movement disorders. Physical Exam: Admission Exam: BP: 74/40, HR 100 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 [x] none Varicosities: None [x] Neuro: Left sided upper and lower extremity weakness Pulses: DP Right: 2+ Left: 2+ [MASKED] Right: 2+ Left: 2+ Radial Right: 1+ Left: 1+ Discharge Exam: 110/49 79SR 16 95% trach collar . General: NAD [x] Neurological: Moves all extremities spontaneously[x] Chemically paralyzed [] sedated [] Follows commands: weak L hand grasp and bilat toe wiggle/extension [x] HEENT: PEERL [x] MMM[x] Cardiovascular: RRR [x] Irregular [] Murmur, II/VI upper LSB [x] Respiratory: Clear but decreased L>R [x] No resp distress [x] Intubated [] trach site c/d/I [x] increased secretions [x] GU/Renal: Urine clear [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] mild tenderness w/deep palp LUQ [x] flexiseal [MASKED] place [x] PEG c/d/i-no erythema [x] Extremities: Right Upper extremity Warm [x] Edema tr Left Upper extremity Warm [x] Edema tr Right Lower extremity Warm [x] Edema tr Left Lower extremity Warm [x] Edema tr Pulses: DP Right:1 Left:1 [MASKED] Right:1 Left:1 Radial Right:1 Left:Aline [MASKED] place Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] R SC TLC: c/d/I [x] Pertinent Results: STUDIES: PA/LAT CXR [MASKED] (Preliminary): RUE PICC line placed with tip [MASKED] mid SVC. PA/LAT CXR [MASKED] [MASKED] comparison with the study [MASKED], the monitoring support devices are unchanged, as is the left pleural effusion with compressive basilar atelectasis and enlargement of the cardiac silhouette. Indistinctness of pulmonary vessels is consistent with some elevation of pulmonary venous pressure. Chest CTA [MASKED] 1. Type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen, inferior extent not included on the images. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. 2. Small to moderate amount of hemopericardium. Mediastinal blood/hematoma exerts mass-effect with resultant narrowing of the main left and right pulmonary arteries. No active extravasation seen. Transesophageal Echocardiogram [MASKED] PRE-OPERATIVE STATE: Sinus rhythm. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Normal RA size. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Moderate symmetric hypertrophy. Normal cavity size, though the ventricle is significantly underfilled. Normal regional & global systolic function Normal ejection fraction. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: SEVERE ascending dilation. Type A ascending, arch and descending DISSECTION. Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet calcification. Mild (>1.5cm2) stenosis. Mild-moderate [[MASKED]] regurgitation. Central jet. The dissection flap does not involve the aortic valve. Mitral Valve: Normal leaflets. No stenosis. Moderate annular calcification. Mild [1+] regurgitation. Central jet. Tricuspid Valve: Normal leaflets. Pericardium: Moderate effusion. RA systolic collapse/early tamponade. Miscellaneous: Left pleural effusion. POST-OP STATE: The TEE was performed at 21:00:00. Atrial fibrillation. Support: Vasopressor(s): epinephrine. Left Ventricle: Similar to preoperative findings. Global ejection fraction is normal. LV remains underfilled. Right Ventricle: New/worse global dysfunction. RV function is mildly depressed. Aorta: Aortic tube graft [MASKED] position. Dissection [MASKED] aortic arch and descending aorta unchanged. Aortic Valve: No change [MASKED] aortic valve morphology from preoperative state. No change [MASKED] aortic regurgitation. Mitral Valve: No change [MASKED] mitral valve morphology from preoperative state. No change [MASKED] valvular regurgitation from preoperative state. Pericardium: No effusion. Miscellaneous: No pleural effusions. Notification: The surgeon/proceduralist was notified of the findings at the time of the study. Renal Artery Ultrasound [MASKED] Magnitude of vascularity of the left kidney is lower on the left than on the right, suggesting the left renal artery arises from the false lumen and right renal artery from the true lumen as seen on prior CT imaging. However, it was not possible to directly visualize the renal artery origins sonographically due to poor visualization at this time. Left upper extremity ultrasound [MASKED] 1. Deep vein thrombosis with complete occlusion of flow involving the mid to low left internal jugular vein. 2. No evidence of additional deep vein thrombosis [MASKED] the left upper extremity. MR [MASKED] [MASKED] 1. Numerous, scattered acute or early subacute infarcts, majority of which are punctate, however there is a larger approximately 3.0 cm left frontal area of acute or early subacute infarct. No evidence of hemorrhagic conversion. Chronic lacunar infarcts are also noted. 2. Innumerable areas of susceptibility on gradient echo imaging, compatible with amyloid angiopathy. 3. Moderate paranasal sinus disease, as detailed above, including air-fluid levels, suggestive of acute sinusitis. [MASKED] CT [MASKED] 1. Evolving acute infarct [MASKED] the left frontal lobe. No evidence of hemorrhagic conversion. 2. Additional smaller infarcts [MASKED] the bilateral cerebral hemispheres and cerebellar hemispheres are better appreciated on prior MRI. Chest CT [MASKED] 1. Multifocal bilateral ground-glass, nodular opacities and consolidation [MASKED] both lower lobes, worse on the left are likely secondary to multifocal pneumonia. 2. New small bilateral pleural effusions. 3. Type A aortic dissection incompletely characterized [MASKED] this study, with new hyperdense material at the ascending aorta, likely related to the repair. Atherosclerotic plaque CT outline the true lumen [MASKED] the remainder thoracic aorta which appears not significantly changed [MASKED] caliber from prior. Chest CT [MASKED] 1. Nodular peribronchovascular airspace disease [MASKED] the dependent aspect of the right upper lobe and basal aspects of the right middle and lower lobes most likely represents bronchopneumonia. The overall disease burden is decreased (especially [MASKED] the dependent aspect of the right upper lobe) compared to prior CT studies. 2. Please note that it is difficult to differentiate atelectasis from consolidation on a non contrasted study. However, airspace opacification [MASKED] the dependent aspect of the left upper lobe and superior segment of the left lower lobe most likely represents atelectasis. Ground-glass airspace opacification [MASKED] the left lower lobe is nonspecific. 3. Small left-sided pleural effusion. 4. Patient is status post aortic root repair. Residual post dissection changes are difficult to assess on a noncontrast study. CT Aorta and branches [MASKED] The aorta measures 3.5 cm [MASKED] the proximal portion, 3.5 cm [MASKED] mid portion and 3.4 cm [MASKED] the distal abdominal aorta. There is suboptimal visualization of the mid and distal aorta due to overlying bowel gas, tortuosity of the aorta, and body habitus. The known aortic dissection is re-demonstrated. There is echogenic material within the distal aorta which is consistent with thrombus, however size comparison to prior exam is difficult due to limited sonographic windows. The iliac arteries are not visualized. IMPRESSION: Technically limited assessment of the distal abdominal aorta however intraluminal echogenic material corresponds to the known thrombus, however size comparison is difficult. If further comparison is desired and the patient cannot tolerate a CTA, non-contrast MRI with multiplanar imaging could be performed. MICRO: [MASKED] 1:08 pm Mini-BAL **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND SINGLY. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL. YEAST. [MASKED] CFU/mL. [MASKED] 11:15 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [MASKED] C. difficile PCR (Final [MASKED]: NEGATIVE. [MASKED] 8:39 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: YEAST. >100,000 CFU/mL. [MASKED] 9:41 pm Mini-BAL **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. YEAST. ~5000 CFU/mL. [MASKED] 11:30 am SPUTUM Source: Endotracheal. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. YEAST. MODERATE GROWTH. ASPERGILLUS FUMIGATUS COMPLEX. SUSCEPTIBILITIES REQUESTED PER [MASKED] [MASKED] ([MASKED]) ON [MASKED]. Refer to sendout/miscellaneous reporting for results. SENT TO [MASKED] ON [MASKED]. LABS: Admit: [MASKED] 02:05PM BLOOD WBC-10.7* RBC-3.83* Hgb-10.8* Hct-34.4 MCV-90 MCH-28.2 MCHC-31.4* RDW-14.2 RDWSD-46.2 Plt [MASKED] [MASKED] 02:05PM BLOOD [MASKED] PTT-27.2 [MASKED] [MASKED] 08:15AM BLOOD HIT Ab-NEG HIT [MASKED] [MASKED] 08:15AM BLOOD HIT Ab-NEG HIT [MASKED] [MASKED] 02:05PM BLOOD Glucose-141* UreaN-21* Creat-0.9 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 [MASKED] 03:45AM BLOOD ALT-12 AST-40 LD(LDH)-476* AlkPhos-27* Amylase-23 TotBili-0.7 [MASKED] 03:26PM BLOOD Lipase-1429* [MASKED] 03:45AM BLOOD Albumin-2.5* Calcium-8.7 Phos-3.7 Mg-2.4 [MASKED] 08:15AM BLOOD Triglyc-187* [MASKED] 03:00AM BLOOD Cortsol-20.9* Discharge: [MASKED] 03:04AM BLOOD WBC-10.0 RBC-2.64* Hgb-7.9* Hct-25.6* MCV-97 MCH-29.9 MCHC-30.9* RDW-16.5* RDWSD-56.2* Plt [MASKED] [MASKED] 03:04AM BLOOD [MASKED] PTT-85.3* [MASKED] [MASKED] 12:52AM BLOOD [MASKED] PTT-68.7* [MASKED] [MASKED] 02:06AM BLOOD [MASKED] PTT-66.2* [MASKED] [MASKED] 09:38AM BLOOD [MASKED] PTT-70.2* [MASKED] [MASKED] 02:40AM BLOOD [MASKED] PTT-82.5* [MASKED] [MASKED] 01:37PM BLOOD [MASKED] PTT-76.1* [MASKED] [MASKED] 03:03AM BLOOD [MASKED] PTT-77.7* [MASKED] [MASKED] 03:04AM BLOOD Glucose-126* UreaN-45* Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-24 AnGap-16 [MASKED] 12:52AM BLOOD Glucose-147* UreaN-51* Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-25 AnGap-15 [MASKED] 02:06AM BLOOD ALT-16 AST-24 LD(LDH)-259* AlkPhos-97 Amylase-368* TotBili-0.2 [MASKED] 03:08AM BLOOD ALT-8 AST-19 LD(LDH)-390* AlkPhos-69 Amylase-716* TotBili-0.6 [MASKED] 02:06AM BLOOD Lipase-403* [MASKED] 02:58PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.8 Brief Hospital Course: She was admitted emergently on [MASKED]. A CTA of the chest confirmed a type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. She was taken to the operating room and under went Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch and repair of small liver laceration. Please see operative note for full details. She tolerated the procedure and was transferred to the CVICU on multiple pressors and inotropes and paralytics with an open sternotomy for recovery and invasive monitoring. She was volume overloaded on arrival and was started on a Lasix infusion for aggressive diuresis. She returned to the OR for chest closure on [MASKED]. She was weaned off of paralytics and sedation. The patient remained lethargic and given her prior history of CVA neurology was consulted. An MRI was obtained which revealed a frontal CVA. A follow up [MASKED] CT showed no evidence of hemorrhagic conversion. Given her embolic CVA, evidence of left IJ thrombus on ultrasound and clot seen on CTA [MASKED] the abdominal aorta, she was started on heparin. The patient's mental status continued to wax and wane and she had persistent encephalopathy and weakness. On [MASKED] an EEG showed discharges consistent with early seizure activity. She was loaded with Keppra. A repeat CT did not show evidence of further CVA. The patient developed fevers and cultures were sent. A chest CT showed evidence of PNA and she had continued difficulty weaning from the ventilator. She was started on empiric Vanco/Cefepime which was then narrowed to an empiric course of cefepime per the ID team. She grew Aspergillus from sputum cultures and the decision was made to treat this with Voriconazole then changed to Isavuconazole due to a prolonged QTc. Cefepime was stopped due to her seizure activity. She was extubated on [MASKED] however she became acutely short of breath and was reintubated. Given her other comorbities the decision was made to proceed with Trach/PEG on [MASKED]. She gradually continued with trach collar trials. She has a history of atrial fibrillation and developed intermittent atrial fibrillation that was treated with Lopressor, Amiodarone was held due to prolonged QTc. During this prolonged ICU stay she also developed [MASKED]. Nephrolgy was also consulted, her diuretics were limited and she was started on free water flushes via PEG. Slowly her renal function trended back to her baseline levels. She continues to receive free water flushes for hypernatremia. She continues to be encephalopathic but this has been improving slowly, she is responsive and follows some simple commands. She has been tolerating progressively longer periods of time on trach collar (daytime trials began [MASKED] and she began 24h ATC TC [MASKED]. She is [MASKED] sinus rhythm and has not had any post-op Afib for several weeks. Her anticoagulation is for afib/DVT and aortic thrombus, continues on heparin bridging and slowly being converted to Coumadin. Goal INR is [MASKED], goal PTT is 50-70. She is tolerating her tube feeds, did have elevated pancreatic enzymes initially. These trended down when she was placed on elemental tube feeds and have continued to trend down for the past 2 weeks. She had yeast [MASKED] both BAL and urine and was started on antifungals (Isavuconazole), this therapy will continue for 6 weeks from start date of [MASKED] with end date [MASKED] and she requires weekly CBC/LFTs per ID recs. Regarding her Keppra and Coumadin duration, these will be reviewed by her neurologist Dr. [MASKED] at a 1 month [MASKED] clinic visit with CTA Torso. She will also need 1 month clinic visit with Vascular team. On, [MASKED] LUE PICC was attempted but could not thread wire and then successfully placed RUE PICC. CXR at that time showed L collapse, so recruitment maneuver done and placed back on PEEP 10. Speech recommdation is that she will likely need trach downsize prior to tolerance of PMV. She was discharged POD 34 to [MASKED] [MASKED] [MASKED] with follow up instructions. Medications on Admission: 1. Diltiazem Extended-Release 180 mg PO Q12H 2. Gabapentin 300 mg PO BID 3. Gabapentin 600 mg PO QHS 4. amLODIPine 1.25 mg PO DAILY 5. Simvastatin 10 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 4. Artificial Tears GEL 1% 1 DROP BOTH EYES Q4H 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 8. Glucose Gel 15 g PO PRN hypoglycemia protocol 9. HydrALAZINE 10 mg IV Q6H:PRN HTN 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 12. Isavuconazonium Sulfate 372 mg PO DAILY Aspergillus PNA Duration: 6 Weeks start date [MASKED] expected finish date [MASKED] 13. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 14. LevETIRAcetam 500 mg PO Q12H 15. Metoprolol Tartrate 25 mg PO TID Hold for HR<60,SBP<90 16. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash 17. Nystatin Oral Suspension 5 mL PO TID 18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 19. Ramelteon 8 mg PO QHS:PRN insomnia 20. Senna 8.6 mg PO BID:PRN Constipation - First Line 21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 22. [MASKED] MD to order daily dose PO DAILY16 23. Warfarin 5 mg PO ONCE Duration: 1 Dose (h/o: postop Afib, aortic thrombus and LIJ DVT) goal INR [MASKED] 24. Simvastatin 10 mg PO QPM 25. HELD- Aspirin 325 mg PO DAILY This medication was held. Do not restart Aspirin until cleared by neurology (Dr. [MASKED] 26. HELD- Diltiazem Extended-Release 180 mg PO Q12H This medication was held. Do not restart Diltiazem Extended-Release until you see cardiologist Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Primary: Type A Aortic Dissection s/p ascending aortic replacement Hosp acquired pneumonia/Resp failure s/p trach & PEG placement Acute kidney injury CVA-left frontal infarct w/associated seizure activity postop Atrial Fibrillation Deep Vein Thrombosis Liver Laceration Hypernatremia Aspergillus Pneumonia elevated Pancreatic enzymes Secondary: PMH: CVA(left sided weakness/pronator drift), Sjogrens syndrome, HLD, HTN, peripheral neuropathy. PSH: Ex-lap for SBO, Lumbar surgery [MASKED], breast biopsyx2 (negative) Discharge Condition: Neuro: opens eyes to voice, moves UE spontaneously, lightly squeezes both hands Full care and lift Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace PICC RUE- c/d/i Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then [MASKED] the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [MASKED]
[]
[ "J9601", "D62", "D696", "I480", "I10" ]
[ "I7101: Dissection of thoracic aorta", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "J9601: Acute respiratory failure with hypoxia", "T8111XA: Postprocedural cardiogenic shock, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "N170: Acute kidney failure with tubular necrosis", "I314: Cardiac tamponade", "J95851: Ventilator associated pneumonia", "I69954: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side", "I82C12: Acute embolism and thrombosis of left internal jugular vein", "G9340: Encephalopathy, unspecified", "B441: Other pulmonary aspergillosis", "D62: Acute posthemorrhagic anemia", "I313: Pericardial effusion (noninflammatory)", "J90: Pleural effusion, not elsewhere classified", "K9172: Accidental puncture and laceration of a digestive system organ or structure during other procedure", "E873: Alkalosis", "I7409: Other arterial embolism and thrombosis of abdominal aorta", "E870: Hyperosmolality and hypernatremia", "J9819: Other pulmonary collapse", "E854: Organ-limited amyloidosis", "I97190: Other postprocedural cardiac functional disturbances following cardiac surgery", "G629: Polyneuropathy, unspecified", "M3500: Sicca syndrome, unspecified", "E8770: Fluid overload, unspecified", "R569: Unspecified convulsions", "D696: Thrombocytopenia, unspecified", "I4581: Long QT syndrome", "E8351: Hypocalcemia", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "I680: Cerebral amyloid angiopathy", "M1990: Unspecified osteoarthritis, unspecified site", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "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", "M549: Dorsalgia, unspecified", "R948: Abnormal results of function studies of other organs and systems", "E8339: Other disorders of phosphorus metabolism", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure" ]
10,057,731
26,763,521
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain, jaundice Major Surgical or Invasive Procedure: ERCP/EUS with biopsies and Biliary stenting ___ History of Present Illness: ___ yo M with seizure disorder and chronic low back pain who presents with abdominal pain and jaundice. Pt reports abdominal pain that started in the LUQ on ___ and progressed to include the RUQ over the following day. He noticed that he was jaundiced on ___ w/ tea colored urine and pale stools. He also endorses pruritus. He went to the ED at ___ on ___ and reportedly was found to have a mass at the head of the pancreas and hepatic lesions. He saw his PCP today who referred him to ___ for evaluation. In the ED, pt afebrile w/ WBC 8.5k. Labs notable for ALT 79, AST 43, Alk 829, Tb 22.6. ERCP was consulted who recommended NPO for ERCP tomorrow and antibiotic ppx w/ cipro/flagyl. Pt otherwise denies any weight loss, chronic abdominal pain, or diarrhea. ROS: As above. Denies headache, lightheadedness, dizziness, sore throat, sinus congestion, chest pain, heart palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, urinary symptoms, muscle or joint pains, focal numbness or tingling, skin rash. The remainder of the ROS was negative. Past Medical History: PMHx: - Distant ex-lap ___ stabbing - chronic back pain w/ prior lumbar discectomy - seizure disorder, currently off meds - HTN - depression Social History: ___ Family History: No family history of GI illness or malignancy. Pertinent Results: HBsAg: NEG HBs Ab: NEG HBc Ab: NEG HAV Ab: NEG Hep C Ab: POS** --> Viral load negative *Cytology Pending ___ ALT: 48* AST: 37 AlkPhos: 649* TotBili: 24.4* ___ ALT: 46* AST: 51* AlkPhos: 587* TotBili: 23.9* MRCP ___: Results IMPRESSION: 1. 6.0 cm centrally necrotic mass in the tail the pancreas obliterating the splenic vein, intimately associated with the splenic artery, and abutting but not clearly involving the inferior aspect of the stomach, consistent with primary pancreatic neoplasm. No extension to the splenic hilum. 2. Numerous hepatic metastases including to the hepatic hilum causing diffuse intrahepatic biliary ductal dilation and multifocal areas of intrahepatic iliary ductal tree stricturing, including involving the left and right anterior and posterior hepatic ducts as well as more distal segmental biliary tree branches. 3. Peribiliary enhancement is concerning for superimposed cholangitis. 4. Enlarged periportal lymph nodes are concerning for nodal metastases. 5. Right portal vein is occluded. Patent left and main portal vein. Patent SMV. 6. Upper abdominal varices are noted including along the lesser curvature of the stomach. No splenomegaly or ascites. 7. 2 cm right adrenal adenoma. Other incidental findings, as above. ERCP ___ The scout film was normal. •There was mild duodenitis. •The bile duct was deeply cannulated with the sphincterotome. •Contrast was injected and there was brisk flow through the ducts. •Contrast extended to the entire biliary tree. The CBD was 6 mm in diameter. •Opacification of the gallbladder was incomplete. •There was evidence of a hilar stricture involving both the CHD, as well as left and right main intrahepatic ducts. •The total length of the stricture was 3 cm. •This is compatible with a Type IV hilar stricture. •A biliary sphincterotomy was made with a sphincterotome. •There was no post-sphincterotomy bleeding. •Both the right and left IHD were cannulated with wires using standard double-wire technique. •A 6 mm hurricane dilation balloon was used to dilaton the right and left main ducts as well as CHD. Cytology brushings of the hilum were performed. •A ___ x 15 cm biliary plastic straight stent was placed into the right IHD. •An 8.5 F x 14 cm biliary plastic straight stent was attempted to be placed into the left IHD but was unable to traverse the stricture and thus was removed with a snare. •A ___ x 14 cm biliary plastic straight stent was then placed into the left main IHD successfully after repeat hurricane dilation with 6 mm balloon. •Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. •Otherwise normal ercp to third part of the duodenum EUS ___ Impression: •A focused 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. •Pancreas Tail Mass: A 6 cm X 7 cm ill-defined mass was noted in the tail of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. •FNB was performed of the mass. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge Sharkcore needle with a stylet was used to perform biopsy. Four needle passes were made into the mass. •25 gauge FNA was also performed of the mass with two passes. •No appreciable liver lesions were identified for biopsy. •Otherwise normal upper eus to third part of the duodenum Brief Hospital Course: ___ yo M with h/o HTN, chronic back pain, who presents with jaundice and outside imaging with finding of mass within the pancreas # Necrotic Pancreatic Mass - Pancreatic tail mass with possible metastasis to liver and regional lymph nodes. EUS/ERCP done on ___ and obtained FNA of tumor and cytology brushings of bile duct for pathology (with preliminary findings of adenocarcinoma; Onc aware and will be followed up outpatient). At time of discharge d/c'd home with PO oxycodone for moderate pain (increased from home dose of 10mg to 15mg) # Hyperbilirubinemia and Elevated LFTs - Most likely from mass and obstruction from lymph notes. Stenting ___. To follow up with ERCP team in 4 weeks # Periportal enhancement on MRCP - Possible Cholangitis? Will treat for duration of Cholangitis course ___ days - intervention on ___. Cipro/flagyl - End date ___ # Portal vein thrombosis as above - STarted on heparin ggt due to thrombosis. Restarted on Subcutaneous lovenox prior to discharge. # Hep C Ab + - Viral Load negative # HTN - continue metoprolol 50 daily. Restart losartan and chlorthalidone on discharge # Depression/Anxiety - continue sertraline. Started Alprazolam inpatient due to overwhelming anxiety during diagnosis stage of his pancreatic cancer # Adrenal Adenoma - Incidental 2cm mass. If indicated, repeat imaging in ___ months Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 5. Sertraline 100 mg PO DAILY Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN Anxiety RX *alprazolam 1 mg 1 tablet(s) by mouth Three times a day as needed for anxiety Disp #*15 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Every 12 hours Disp #*12 Tablet Refills:*0 3. Enoxaparin Sodium 110 mg SC Q12H RX *enoxaparin 100 mg/mL 110 mg Subcutaneous injecton Every 12 hours Disp #*60 Syringe Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Every 8 hours Disp #*18 Tablet Refills:*0 5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings RX *nicotine (polacrilex) [Nicorette] 2 mg Every 4 hours as needed for craving Every 4 hours as needed for craving Disp #*60 Lozenge Refills:*0 6. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 1 patch daily for smoking cravings 1 patch daily for smoking cravings Disp #*30 Patch Refills:*0 7. Chlorthalidone 25 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 11. Sertraline 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pancreatic Cancer Hyperbilirubinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, You were admitted for abdominal pain and jaundice. It was found that you had a large mass in your pancreas that looks like it had spread to your lymph nodes and to your liver. During you stay you had an MRI of your biliary system and also a procedure called an ERCP in which we took biopsies of your lesion and also brushings of your bile duct. We stented your bile duct so it should be draining OK. The ERCP team want to see you back in 4 weeks to re-evaluate and pull the stent. The final results of the brushings and samples taken will be followed up by oncology. Please expect a call from them or call them within 1 week of discharge. You were also started on Lovenox for a clot in your right portal vein. It was a pleasure being part of your care Your ___ Team Followup Instructions: ___
[ "C259", "K831", "I81", "K830", "I10", "F329", "G8929", "D3500", "Z86718", "F17210", "J45909", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain, jaundice Major Surgical or Invasive Procedure: ERCP/EUS with biopsies and Biliary stenting [MASKED] History of Present Illness: [MASKED] yo M with seizure disorder and chronic low back pain who presents with abdominal pain and jaundice. Pt reports abdominal pain that started in the LUQ on [MASKED] and progressed to include the RUQ over the following day. He noticed that he was jaundiced on [MASKED] w/ tea colored urine and pale stools. He also endorses pruritus. He went to the ED at [MASKED] on [MASKED] and reportedly was found to have a mass at the head of the pancreas and hepatic lesions. He saw his PCP today who referred him to [MASKED] for evaluation. In the ED, pt afebrile w/ WBC 8.5k. Labs notable for ALT 79, AST 43, Alk 829, Tb 22.6. ERCP was consulted who recommended NPO for ERCP tomorrow and antibiotic ppx w/ cipro/flagyl. Pt otherwise denies any weight loss, chronic abdominal pain, or diarrhea. ROS: As above. Denies headache, lightheadedness, dizziness, sore throat, sinus congestion, chest pain, heart palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, urinary symptoms, muscle or joint pains, focal numbness or tingling, skin rash. The remainder of the ROS was negative. Past Medical History: PMHx: - Distant ex-lap [MASKED] stabbing - chronic back pain w/ prior lumbar discectomy - seizure disorder, currently off meds - HTN - depression Social History: [MASKED] Family History: No family history of GI illness or malignancy. Pertinent Results: HBsAg: NEG HBs Ab: NEG HBc Ab: NEG HAV Ab: NEG Hep C Ab: POS** --> Viral load negative *Cytology Pending [MASKED] ALT: 48* AST: 37 AlkPhos: 649* TotBili: 24.4* [MASKED] ALT: 46* AST: 51* AlkPhos: 587* TotBili: 23.9* MRCP [MASKED]: Results IMPRESSION: 1. 6.0 cm centrally necrotic mass in the tail the pancreas obliterating the splenic vein, intimately associated with the splenic artery, and abutting but not clearly involving the inferior aspect of the stomach, consistent with primary pancreatic neoplasm. No extension to the splenic hilum. 2. Numerous hepatic metastases including to the hepatic hilum causing diffuse intrahepatic biliary ductal dilation and multifocal areas of intrahepatic iliary ductal tree stricturing, including involving the left and right anterior and posterior hepatic ducts as well as more distal segmental biliary tree branches. 3. Peribiliary enhancement is concerning for superimposed cholangitis. 4. Enlarged periportal lymph nodes are concerning for nodal metastases. 5. Right portal vein is occluded. Patent left and main portal vein. Patent SMV. 6. Upper abdominal varices are noted including along the lesser curvature of the stomach. No splenomegaly or ascites. 7. 2 cm right adrenal adenoma. Other incidental findings, as above. ERCP [MASKED] The scout film was normal. •There was mild duodenitis. •The bile duct was deeply cannulated with the sphincterotome. •Contrast was injected and there was brisk flow through the ducts. •Contrast extended to the entire biliary tree. The CBD was 6 mm in diameter. •Opacification of the gallbladder was incomplete. •There was evidence of a hilar stricture involving both the CHD, as well as left and right main intrahepatic ducts. •The total length of the stricture was 3 cm. •This is compatible with a Type IV hilar stricture. •A biliary sphincterotomy was made with a sphincterotome. •There was no post-sphincterotomy bleeding. •Both the right and left IHD were cannulated with wires using standard double-wire technique. •A 6 mm hurricane dilation balloon was used to dilaton the right and left main ducts as well as CHD. Cytology brushings of the hilum were performed. •A [MASKED] x 15 cm biliary plastic straight stent was placed into the right IHD. •An 8.5 F x 14 cm biliary plastic straight stent was attempted to be placed into the left IHD but was unable to traverse the stricture and thus was removed with a snare. •A [MASKED] x 14 cm biliary plastic straight stent was then placed into the left main IHD successfully after repeat hurricane dilation with 6 mm balloon. •Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. •Otherwise normal ercp to third part of the duodenum EUS [MASKED] Impression: •A focused 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. •Pancreas Tail Mass: A 6 cm X 7 cm ill-defined mass was noted in the tail of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. •FNB was performed of the mass. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge Sharkcore needle with a stylet was used to perform biopsy. Four needle passes were made into the mass. •25 gauge FNA was also performed of the mass with two passes. •No appreciable liver lesions were identified for biopsy. •Otherwise normal upper eus to third part of the duodenum Brief Hospital Course: [MASKED] yo M with h/o HTN, chronic back pain, who presents with jaundice and outside imaging with finding of mass within the pancreas # Necrotic Pancreatic Mass - Pancreatic tail mass with possible metastasis to liver and regional lymph nodes. EUS/ERCP done on [MASKED] and obtained FNA of tumor and cytology brushings of bile duct for pathology (with preliminary findings of adenocarcinoma; Onc aware and will be followed up outpatient). At time of discharge d/c'd home with PO oxycodone for moderate pain (increased from home dose of 10mg to 15mg) # Hyperbilirubinemia and Elevated LFTs - Most likely from mass and obstruction from lymph notes. Stenting [MASKED]. To follow up with ERCP team in 4 weeks # Periportal enhancement on MRCP - Possible Cholangitis? Will treat for duration of Cholangitis course [MASKED] days - intervention on [MASKED]. Cipro/flagyl - End date [MASKED] # Portal vein thrombosis as above - STarted on heparin ggt due to thrombosis. Restarted on Subcutaneous lovenox prior to discharge. # Hep C Ab + - Viral Load negative # HTN - continue metoprolol 50 daily. Restart losartan and chlorthalidone on discharge # Depression/Anxiety - continue sertraline. Started Alprazolam inpatient due to overwhelming anxiety during diagnosis stage of his pancreatic cancer # Adrenal Adenoma - Incidental 2cm mass. If indicated, repeat imaging in [MASKED] months Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 5. Sertraline 100 mg PO DAILY Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN Anxiety RX *alprazolam 1 mg 1 tablet(s) by mouth Three times a day as needed for anxiety Disp #*15 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Every 12 hours Disp #*12 Tablet Refills:*0 3. Enoxaparin Sodium 110 mg SC Q12H RX *enoxaparin 100 mg/mL 110 mg Subcutaneous injecton Every 12 hours Disp #*60 Syringe Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Every 8 hours Disp #*18 Tablet Refills:*0 5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings RX *nicotine (polacrilex) [Nicorette] 2 mg Every 4 hours as needed for craving Every 4 hours as needed for craving Disp #*60 Lozenge Refills:*0 6. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 1 patch daily for smoking cravings 1 patch daily for smoking cravings Disp #*30 Patch Refills:*0 7. Chlorthalidone 25 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 11. Sertraline 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pancreatic Cancer Hyperbilirubinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [MASKED], You were admitted for abdominal pain and jaundice. It was found that you had a large mass in your pancreas that looks like it had spread to your lymph nodes and to your liver. During you stay you had an MRI of your biliary system and also a procedure called an ERCP in which we took biopsies of your lesion and also brushings of your bile duct. We stented your bile duct so it should be draining OK. The ERCP team want to see you back in 4 weeks to re-evaluate and pull the stent. The final results of the brushings and samples taken will be followed up by oncology. Please expect a call from them or call them within 1 week of discharge. You were also started on Lovenox for a clot in your right portal vein. It was a pleasure being part of your care Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10", "F329", "G8929", "Z86718", "F17210", "J45909", "Z7902" ]
[ "C259: Malignant neoplasm of pancreas, unspecified", "K831: Obstruction of bile duct", "I81: Portal vein thrombosis", "K830: Cholangitis", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G8929: Other chronic pain", "D3500: Benign neoplasm of unspecified adrenal gland", "Z86718: Personal history of other venous thrombosis and embolism", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,057,731
29,234,056
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Bilateral PTBD drain placement L JP drain placement Internal/external PTBD drain placement History of Present Illness: Mr. ___ is a ___ year old male with a history of mestastatic pancreatic cancer s/p ERCP ___ d/c'd from ___ ___, who presented to ___ for altered mental status. The patient was recently admitted to ___ on ___ for back pain, and jaundice and tea colored urine. Was found to have pancreatic tail mass with metastasis to liver and regional lymph nodes suggested by EUS/ERCP on ___ w/ FNA of tumor and cytology brushings of bile duct for pathology (with preliminary findings of adenocarcinoma). due to elevation in bili, biliary stent were placed to treat biliary obstruction from LN mass effect. MRCP was done and suggest cholangitis an dhe was treated with cipro and flagyl (end date ___. Also found to have Pv thrombosis and was started on levenox SQ. The plan was to discharge him on a higher oxycodone dose than his pre admission dose (15mg from 10mg) to control his pain and follow up with oncology as an outpt. Presented to ___ with altered mental status responding to narcan with moderate improvement in her mental status from somnolent to confused. His urine output fell to none. Initial labs are notable for - Cr of 14 (bl of 0.9) - K 7 - PH 7.16 in ___ he received: - 6L NS for his ___ and sepsis and lowe UOP - zosyn and vanco - calcium, gluc, bicarb, 2 amps d50 and 10 units regular insulin, nebs. He was transferred to ___ for further care. In the ED ============== Initial vitals: 96.8 73 123/94 16 94% 4L NC He was found to have a leukocytosis and was treated with Vancomycin and Zosyn with concern for post ERCP related sepsis and the ERCP team was notified. He was also becoming hypotensive in the ED BPs in the ___ and was given albumin and his HCP (___ ___ was contacted and consented to central line placement and HD line placement. Past Medical History: PMHx: - Distant ex-lap ___ stabbing - chronic back pain w/ prior lumbar discectomy - seizure disorder, currently off meds - HTN - depression Social History: ___ Family History: No family history of GI illness or malignancy. Physical Exam: ADMISSION EXAM: =============== VITALS: HR= 66 BP=106/59 Sp2=93% on 5L NC. GENERAL: the patient is confused. not in distress. EYES: Overt jaundice sclera. PERRL. ENT: Moist oral mucosa CV: Heart regular, no murmur, no S3, no S4. RESP: good air movement bilaterally. some crackles on the left base. Breathing is non-labored GI: Abdomen soft, non-distended, slight tenderness to palpation in upper abdomen. midline scar noted as well as round ecchimosese. 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 but appears yellow and jaundiced 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: =============== VS: No longer checking - CMO GENERAL: Middle-aged man, sitting in bed comfortably, in no acute distress HEENT: NC/AT, EOMI, jaundiced sclera GI: Obese, active bowel sounds, soft, non-tender to palpation, R/L PTBD and L JP drain in place, dressings c/d/i SKIN: Jaundiced NEURO: Alert, oriented, face symmetric, speech fluent, moving all extremities with purpose Pertinent Results: ADMISSION LABS: =============== ___ 09:55PM ___ PO2-40* PCO2-46* PH-7.19* TOTAL CO2-18* BASE XS--11 ___ 08:31PM ___ PO2-44* PCO2-37 PH-7.17* TOTAL CO2-14* BASE XS--15 ___ 08:31PM O2 SAT-63 ___ 08:31PM GLUCOSE-115* K+-4.5 ___ 08:25PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 07:30PM URINE HOURS-RANDOM ___ 07:30PM URINE bnzodzpn-POS* barbitrt-NEG opiates-POSITIVE* cocaine-NEG amphetmn-NEG oxycodn-UNABLE TO mthdone-NEG ___ 07:30PM URINE COLOR-Yellow APPEAR-Cloudy* SP ___ ___ 07:30PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100* GLUCOSE-100* KETONE-TR* BILIRUBIN-LG* UROBILNGN-1 PH-6.0 LEUK-NEG ___ 07:30PM URINE ___ BACTERIA-FEW* YEAST-NONE ___ 06:01PM LACTATE-2.0 K+-6.2* ___ 05:50PM GLUCOSE-127* UREA N-190* CREAT-12.0*# SODIUM-133* POTASSIUM-6.5* CHLORIDE-90* TOTAL CO2-15* ANION GAP-28* ___ 05:50PM estGFR-Using this ___ 05:50PM ALT(SGPT)-51* AST(SGOT)-89* ALK PHOS-467* TOT BILI-26.5* ___ 05:50PM LIPASE-49 ___ 05:50PM ALBUMIN-2.4* CALCIUM-7.6* PHOSPHATE-11.3* MAGNESIUM-3.1* ___ 05:50PM OSMOLAL-347* ___ 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 05:50PM WBC-17.5* RBC-2.55* HGB-8.0* HCT-23.5* MCV-92 MCH-31.4 MCHC-34.0 RDW-17.5* RDWSD-58.7* ___ 05:50PM NEUTS-84.6* LYMPHS-4.4* MONOS-9.7 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-14.79* AbsLymp-0.77* AbsMono-1.69* AbsEos-0.00* AbsBaso-0.01 ___ 05:50PM PLT COUNT-332 ___ 05:50PM ___ PTT-35.2 ___ MICRO: ====== ___ 5:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:59 am BLOOD CULTURE Source: Line-aline 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:00 am BLOOD CULTURE Source: Line-VIP port on HD line 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:52 am BILE #2 DRAIN. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): YEAST(S). FLUID CULTURE (Final ___: ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 8:52 am BILE # 1 DRAIN. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): BUDDING YEAST. FLUID CULTURE (Final ___: ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. YEAST, PRESUMPTIVELY NOT C. ALBICANS. MODERATE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. IMAGING: ======== CXR ___: Low lung volumes with bibasilar atelectasis. 2 biliary stents seen in the right upper quadrant of the abdomen LIVER US ___: 1. Limited exam. Main portal vein is patent. Right anterior and posterior portal veins are not visualized, compatible with the history of occlusion as seen on the recent MRI. Left portal vein was not visualized on this exam. 2. Persistent moderate intrahepatic biliary duct dilatation. RECOMMENDATION(S): Consider further assessment with contrast enhanced CT or MR for better evaluation of the right and left portal venous branches. CT Abd/Pelvis w/o contrast ___ 1. 2 side-by-side common bile duct stents extending into the proximal left and right biliary systems and terminate at the junction of the second and third portions of the duodenum. There is persistent moderate intrahepatic biliary dilatation. 2. Multiple hepatic masses and pancreatic tail mass are better assessed on recent MRCP. Pancreatic mass is grossly unchanged in size. 3. Unchanged right adrenal adenoma. 4. Unchanged periportal lymphadenopathy. 5. Fluid-filled stomach placing the patient at risk for aspiration. CXR ___: Right internal jugular central venous catheter tip in the mid SVC. Bilateral lower lobe atelectasis. RUQUS ___: Moderate intrahepatic biliary duct dilatation, stable to previous. Thrombosis of the right portal vein. PTBD ___: 1. Diffusely dilated biliary system. 2. Successful placement of right posterior ___ internal-external biliary drain. 3. Successful placement of left 10 ___ external biliary drain. There is communication of the left biliary system with the right anterior biliary system. RECOMMENDATION(S): The patient has optimized drainage for his acute condition. Upon resolution of his sepsis and cholangitis, further interventions related to internalizing the left PTBD and the indwelling plastic stents can be pursued. CXR ___: Right internal jugular line tip is at the level of superior SVC. NG tube tip is in the stomach. Small left pleural effusion is unchanged. ET tube tip is 6.5 cm above the carina. Mild vascular congestion is noted. Linear opacity in the right lower lung is unchanged. CXR ___: ET tube tip is 7 cm above the carina. Right internal jugular line tip is at the level of mid SVC. NG tube tip is in the stomach. Heart size and mediastinum are stable. Lungs are well expanded. Draining catheter is projecting over the right upper quadrant most likely representing biliary drainage. No appreciable pleural effusion or pneumothorax. BILIARY CATH CHECK ___: 1. Successful exchange of 10 ___ right internal/external percutaneous transhepatic biliary drainage catheters with new 10 ___ right internal/external PTBD catheters. 2. Uncomplicated placement of a new l 10 ___ left internal/external PTBD. DISCHARGE LABS: =============== ___ 04:40AM BLOOD WBC-22.2* RBC-2.58* Hgb-8.0* Hct-23.9* MCV-93 MCH-31.0 MCHC-33.5 RDW-17.8* RDWSD-60.5* Plt ___ ___ 04:40AM BLOOD Plt ___ ___ 04:40AM BLOOD ___ PTT-26.3 ___ ___ 04:40AM BLOOD Glucose-172* UreaN-74* Creat-3.0* Na-148* K-2.9* Cl-105 HCO3-25 AnGap-18 ___ 04:40AM BLOOD ALT-43* AST-51* LD(LDH)-346* AlkPhos-347* TotBili-19.1* ___ 04:40AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9 Brief Hospital Course: Mr. ___ is a ___ with past medical history notably for metastatic pancreatic cancer, who initially presented to ___ with altered mental status, transferred to ___ for septic/hemorrhagic shock due to cholangitis and acute renal failure requiring initiation of CRRT. Patient ultimately decided to forego cancer directed therapy and instead transition to comfort-measures only, and was discharged home with hospice. ACTIVE ISSUES: =============== # Septic Shock # Cholangitis and Biliary obstruction Presented with septic shock requiring admission to ICU for pressors. Source felt to be biliary in light of rising T bili. Underwent ERCP with placement of bilateral PTBD drains. Started on broad spectrum antibiotics, ultimately narrowed to cefepime and flagyl. LFTS initially improved, then started to uptrend, concerning for new obstruction. ___ consulted and found that PTBD drains had been pulled back; placed new internal/external drain with improvement in abdominal pain and stabilization of labs. Cultures unremarkable. D/c'd on augmentin to complete 10 day course (last day ___ # Acute Renal Failure # Anion gap metabolic acidosis # Hyperkalemia Baseline Cr 0.9, up-trended to 13.2, felt to be due to ATN ___ septic and hemorrhagic shock. In the ICU, received 6L of crystaloids with no improvement. Renal consulted and patient initiated on CRRT with improvement in Cr. Cr improved to 3.0 and electrolyte abnormalities resolved before decision was made to stop trending labs (see ___ conversation below). # Upper GI bleed Found to have coffee-ground emesis in NGT with downtrending Hgb. Underwent EGD on ___ with no evidence of varicosities. Started on IV PPI BID and eventually transitioned to PO PPI. Transfused as needed to maintain Hgb > 7. Hemoglobin stabilized at approx. 8 and patient required no further transfusions. # Altered mental status Initially presented with AMS, concerning for hepatic encephalopathy vs. uremia vs. opiate overdose. CT head from OSH negative. No focal deficits on exam. Improved with initiation of CRRT for uremia # Acute hypoxic respiratory failure Developed new oxygen requirement and found to have RML/LLL opacification on CXR, concerning for pneumonia. Additionally, aspiration possible in the setting of altered mental status on admission. Treated with vancomycin and zosyn, eventually narrowed to cefepime/flaygl as above. Oxygen requirement resolved and mental status improved. # Pancreatic adenocarcinoma with liver metastasis # Goals of care Pt underwent EUS/ERCP on ___ and obtained FNA of tumor and cytology brushings of bile duct for pathology (consistent with adenocarcinoma). Initiation of chemotherapy initially delayed in setting of acute medical conditions. Once medically stable, goals of care conversation was held with patient and family. Patient clearly expressed that he wished to forgo cancer-directed treatment and wanted to be discharge home with hospice. His code status was changed to DNR/DNI, CMO. CHRONIC ISSUES: =============== # PV thrombosis Prevoiously on SC enoxaparin, held in the setting of active GI bleed. Once hemoglobin stabilized, planned on re-starting; however, patient transitioned to CMO and AC deferred. # HTN Home antihypertensives initially held in the setting of shock. Once hemodynamically stable, blood pressure was within normal limits and did not require treatment. # Depression/Anxiety Continues home sertraline. TRANSITIONAL ISSUES: ==================== [] discharged DNR/DNI, CMO w/ home hospice (___ hospice) [] taking augmentin to complete 14 day course (last day ___ for presumed cholangitis [] If issues with PTBD drains, consider follow-up with ___, if for comfort and within ___ [] Found to have incidental 2cm adrenal adeonoma. Per guidelines, consider repeat imaging in ___ months (however, not within ___ given transition to CMO) [] Has positive Hep C Ab with negative viral load. Not within ___ to follow-up. #CODE: DNR/DNI, CMO (confirmed with MOLST in chart) #CONTACT: ___ (partner/HCP): ___ ___ on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 3. Sertraline 100 mg PO DAILY 4. Enoxaparin Sodium 110 mg SC Q12H 5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings 6. Nicotine Patch 21 mg TD DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. ALPRAZolam 1 mg PO TID:PRN Anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet Refills:*0 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Fentanyl Patch 100 mcg/h TD Q72H RX *fentanyl 100 mcg/hour apply patch to arm q72hrs Disp #*2 Patch Refills:*0 6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate RX *hydromorphone 4 mg 1 tablet(s) by mouth q3hrs Disp #*20 Tablet Refills:*0 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB and wheezing 8. Lidocaine 5% Patch 2 PTCH TD QAM RX *lidocaine [Lidocare] 4 % Apply one patch to back qam Disp #*15 Patch Refills:*0 9. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all dressing changes 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet Refills:*0 11. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 12. Senna 8.6 mg PO DAILY:PRN constipation 13. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings 14. Nicotine Patch 21 mg TD DAILY 15. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: - Septic shock secondary to cholangitis - Acute kidney injury - Upper GI bleed Secondary diagnosis: - Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, Why were you admitted to the hospital? - You were transferred to ___ from ___ because you had an infection that made you extremely sick and confused, requiring an ICU level of care. What was done for you in the hospital? - Your kidneys were extremely damaged, so you received treatment to help improve your kidney function. - You had bleeding in your GI tract and received blood products to support you. You had a procedure to determine the cause of your bleeding. - You had an infection in the gallbladder system, so you received antibiotics. - Your cancer compressed your gallbladder system, so you had a procedure to decompress the area and stents placed to open up the blockages. - You received pain medications for your stomach pain. - You made the decision to transition to comfort-directed care. What should you do when you leave the hospital? - You should continue taking all medications that improve your comfort. - You should call your doctors with any questions or concerns you have. It was a pleasure taking care of you. Sincerely, Your ___ Team Followup Instructions: ___
[ "A419", "R6521", "J9601", "K830", "N179", "C787", "E872", "K831", "I8500", "C259", "E875", "Z515", "Z66", "I10", "F329", "F419", "Z86718", "D3500", "K209", "K2980", "G893" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Bilateral PTBD drain placement L JP drain placement Internal/external PTBD drain placement History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with a history of mestastatic pancreatic cancer s/p ERCP [MASKED] d/c'd from [MASKED] [MASKED], who presented to [MASKED] for altered mental status. The patient was recently admitted to [MASKED] on [MASKED] for back pain, and jaundice and tea colored urine. Was found to have pancreatic tail mass with metastasis to liver and regional lymph nodes suggested by EUS/ERCP on [MASKED] w/ FNA of tumor and cytology brushings of bile duct for pathology (with preliminary findings of adenocarcinoma). due to elevation in bili, biliary stent were placed to treat biliary obstruction from LN mass effect. MRCP was done and suggest cholangitis an dhe was treated with cipro and flagyl (end date [MASKED]. Also found to have Pv thrombosis and was started on levenox SQ. The plan was to discharge him on a higher oxycodone dose than his pre admission dose (15mg from 10mg) to control his pain and follow up with oncology as an outpt. Presented to [MASKED] with altered mental status responding to narcan with moderate improvement in her mental status from somnolent to confused. His urine output fell to none. Initial labs are notable for - Cr of 14 (bl of 0.9) - K 7 - PH 7.16 in [MASKED] he received: - 6L NS for his [MASKED] and sepsis and lowe UOP - zosyn and vanco - calcium, gluc, bicarb, 2 amps d50 and 10 units regular insulin, nebs. He was transferred to [MASKED] for further care. In the ED ============== Initial vitals: 96.8 73 123/94 16 94% 4L NC He was found to have a leukocytosis and was treated with Vancomycin and Zosyn with concern for post ERCP related sepsis and the ERCP team was notified. He was also becoming hypotensive in the ED BPs in the [MASKED] and was given albumin and his HCP ([MASKED] [MASKED] was contacted and consented to central line placement and HD line placement. Past Medical History: PMHx: - Distant ex-lap [MASKED] stabbing - chronic back pain w/ prior lumbar discectomy - seizure disorder, currently off meds - HTN - depression Social History: [MASKED] Family History: No family history of GI illness or malignancy. Physical Exam: ADMISSION EXAM: =============== VITALS: HR= 66 BP=106/59 Sp2=93% on 5L NC. GENERAL: the patient is confused. not in distress. EYES: Overt jaundice sclera. PERRL. ENT: Moist oral mucosa CV: Heart regular, no murmur, no S3, no S4. RESP: good air movement bilaterally. some crackles on the left base. Breathing is non-labored GI: Abdomen soft, non-distended, slight tenderness to palpation in upper abdomen. midline scar noted as well as round ecchimosese. 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 but appears yellow and jaundiced 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: =============== VS: No longer checking - CMO GENERAL: Middle-aged man, sitting in bed comfortably, in no acute distress HEENT: NC/AT, EOMI, jaundiced sclera GI: Obese, active bowel sounds, soft, non-tender to palpation, R/L PTBD and L JP drain in place, dressings c/d/i SKIN: Jaundiced NEURO: Alert, oriented, face symmetric, speech fluent, moving all extremities with purpose Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:55PM [MASKED] PO2-40* PCO2-46* PH-7.19* TOTAL CO2-18* BASE XS--11 [MASKED] 08:31PM [MASKED] PO2-44* PCO2-37 PH-7.17* TOTAL CO2-14* BASE XS--15 [MASKED] 08:31PM O2 SAT-63 [MASKED] 08:31PM GLUCOSE-115* K+-4.5 [MASKED] 08:25PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 07:30PM URINE HOURS-RANDOM [MASKED] 07:30PM URINE bnzodzpn-POS* barbitrt-NEG opiates-POSITIVE* cocaine-NEG amphetmn-NEG oxycodn-UNABLE TO mthdone-NEG [MASKED] 07:30PM URINE COLOR-Yellow APPEAR-Cloudy* SP [MASKED] [MASKED] 07:30PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100* GLUCOSE-100* KETONE-TR* BILIRUBIN-LG* UROBILNGN-1 PH-6.0 LEUK-NEG [MASKED] 07:30PM URINE [MASKED] BACTERIA-FEW* YEAST-NONE [MASKED] 06:01PM LACTATE-2.0 K+-6.2* [MASKED] 05:50PM GLUCOSE-127* UREA N-190* CREAT-12.0*# SODIUM-133* POTASSIUM-6.5* CHLORIDE-90* TOTAL CO2-15* ANION GAP-28* [MASKED] 05:50PM estGFR-Using this [MASKED] 05:50PM ALT(SGPT)-51* AST(SGOT)-89* ALK PHOS-467* TOT BILI-26.5* [MASKED] 05:50PM LIPASE-49 [MASKED] 05:50PM ALBUMIN-2.4* CALCIUM-7.6* PHOSPHATE-11.3* MAGNESIUM-3.1* [MASKED] 05:50PM OSMOLAL-347* [MASKED] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG [MASKED] 05:50PM WBC-17.5* RBC-2.55* HGB-8.0* HCT-23.5* MCV-92 MCH-31.4 MCHC-34.0 RDW-17.5* RDWSD-58.7* [MASKED] 05:50PM NEUTS-84.6* LYMPHS-4.4* MONOS-9.7 EOS-0.0* BASOS-0.1 IM [MASKED] AbsNeut-14.79* AbsLymp-0.77* AbsMono-1.69* AbsEos-0.00* AbsBaso-0.01 [MASKED] 05:50PM PLT COUNT-332 [MASKED] 05:50PM [MASKED] PTT-35.2 [MASKED] MICRO: ====== [MASKED] 5:50 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 7:30 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:59 am BLOOD CULTURE Source: Line-aline 2 OF 2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 6:00 am BLOOD CULTURE Source: Line-VIP port on HD line 1 OF 2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 8:52 am BILE #2 DRAIN. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): YEAST(S). FLUID CULTURE (Final [MASKED]: [MASKED] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. [MASKED] 8:52 am BILE # 1 DRAIN. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ [MASKED] per 1000X FIELD): BUDDING YEAST. FLUID CULTURE (Final [MASKED]: [MASKED] ALBICANS, PRESUMPTIVE IDENTIFICATION. IDENTIFICATION PERFORMED ON CULTURE # [MASKED] [MASKED]. YEAST, PRESUMPTIVELY NOT C. ALBICANS. MODERATE GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. IMAGING: ======== CXR [MASKED]: Low lung volumes with bibasilar atelectasis. 2 biliary stents seen in the right upper quadrant of the abdomen LIVER US [MASKED]: 1. Limited exam. Main portal vein is patent. Right anterior and posterior portal veins are not visualized, compatible with the history of occlusion as seen on the recent MRI. Left portal vein was not visualized on this exam. 2. Persistent moderate intrahepatic biliary duct dilatation. RECOMMENDATION(S): Consider further assessment with contrast enhanced CT or MR for better evaluation of the right and left portal venous branches. CT Abd/Pelvis w/o contrast [MASKED] 1. 2 side-by-side common bile duct stents extending into the proximal left and right biliary systems and terminate at the junction of the second and third portions of the duodenum. There is persistent moderate intrahepatic biliary dilatation. 2. Multiple hepatic masses and pancreatic tail mass are better assessed on recent MRCP. Pancreatic mass is grossly unchanged in size. 3. Unchanged right adrenal adenoma. 4. Unchanged periportal lymphadenopathy. 5. Fluid-filled stomach placing the patient at risk for aspiration. CXR [MASKED]: Right internal jugular central venous catheter tip in the mid SVC. Bilateral lower lobe atelectasis. RUQUS [MASKED]: Moderate intrahepatic biliary duct dilatation, stable to previous. Thrombosis of the right portal vein. PTBD [MASKED]: 1. Diffusely dilated biliary system. 2. Successful placement of right posterior [MASKED] internal-external biliary drain. 3. Successful placement of left 10 [MASKED] external biliary drain. There is communication of the left biliary system with the right anterior biliary system. RECOMMENDATION(S): The patient has optimized drainage for his acute condition. Upon resolution of his sepsis and cholangitis, further interventions related to internalizing the left PTBD and the indwelling plastic stents can be pursued. CXR [MASKED]: Right internal jugular line tip is at the level of superior SVC. NG tube tip is in the stomach. Small left pleural effusion is unchanged. ET tube tip is 6.5 cm above the carina. Mild vascular congestion is noted. Linear opacity in the right lower lung is unchanged. CXR [MASKED]: ET tube tip is 7 cm above the carina. Right internal jugular line tip is at the level of mid SVC. NG tube tip is in the stomach. Heart size and mediastinum are stable. Lungs are well expanded. Draining catheter is projecting over the right upper quadrant most likely representing biliary drainage. No appreciable pleural effusion or pneumothorax. BILIARY CATH CHECK [MASKED]: 1. Successful exchange of 10 [MASKED] right internal/external percutaneous transhepatic biliary drainage catheters with new 10 [MASKED] right internal/external PTBD catheters. 2. Uncomplicated placement of a new l 10 [MASKED] left internal/external PTBD. DISCHARGE LABS: =============== [MASKED] 04:40AM BLOOD WBC-22.2* RBC-2.58* Hgb-8.0* Hct-23.9* MCV-93 MCH-31.0 MCHC-33.5 RDW-17.8* RDWSD-60.5* Plt [MASKED] [MASKED] 04:40AM BLOOD Plt [MASKED] [MASKED] 04:40AM BLOOD [MASKED] PTT-26.3 [MASKED] [MASKED] 04:40AM BLOOD Glucose-172* UreaN-74* Creat-3.0* Na-148* K-2.9* Cl-105 HCO3-25 AnGap-18 [MASKED] 04:40AM BLOOD ALT-43* AST-51* LD(LDH)-346* AlkPhos-347* TotBili-19.1* [MASKED] 04:40AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9 Brief Hospital Course: Mr. [MASKED] is a [MASKED] with past medical history notably for metastatic pancreatic cancer, who initially presented to [MASKED] with altered mental status, transferred to [MASKED] for septic/hemorrhagic shock due to cholangitis and acute renal failure requiring initiation of CRRT. Patient ultimately decided to forego cancer directed therapy and instead transition to comfort-measures only, and was discharged home with hospice. ACTIVE ISSUES: =============== # Septic Shock # Cholangitis and Biliary obstruction Presented with septic shock requiring admission to ICU for pressors. Source felt to be biliary in light of rising T bili. Underwent ERCP with placement of bilateral PTBD drains. Started on broad spectrum antibiotics, ultimately narrowed to cefepime and flagyl. LFTS initially improved, then started to uptrend, concerning for new obstruction. [MASKED] consulted and found that PTBD drains had been pulled back; placed new internal/external drain with improvement in abdominal pain and stabilization of labs. Cultures unremarkable. D/c'd on augmentin to complete 10 day course (last day [MASKED] # Acute Renal Failure # Anion gap metabolic acidosis # Hyperkalemia Baseline Cr 0.9, up-trended to 13.2, felt to be due to ATN [MASKED] septic and hemorrhagic shock. In the ICU, received 6L of crystaloids with no improvement. Renal consulted and patient initiated on CRRT with improvement in Cr. Cr improved to 3.0 and electrolyte abnormalities resolved before decision was made to stop trending labs (see [MASKED] conversation below). # Upper GI bleed Found to have coffee-ground emesis in NGT with downtrending Hgb. Underwent EGD on [MASKED] with no evidence of varicosities. Started on IV PPI BID and eventually transitioned to PO PPI. Transfused as needed to maintain Hgb > 7. Hemoglobin stabilized at approx. 8 and patient required no further transfusions. # Altered mental status Initially presented with AMS, concerning for hepatic encephalopathy vs. uremia vs. opiate overdose. CT head from OSH negative. No focal deficits on exam. Improved with initiation of CRRT for uremia # Acute hypoxic respiratory failure Developed new oxygen requirement and found to have RML/LLL opacification on CXR, concerning for pneumonia. Additionally, aspiration possible in the setting of altered mental status on admission. Treated with vancomycin and zosyn, eventually narrowed to cefepime/flaygl as above. Oxygen requirement resolved and mental status improved. # Pancreatic adenocarcinoma with liver metastasis # Goals of care Pt underwent EUS/ERCP on [MASKED] and obtained FNA of tumor and cytology brushings of bile duct for pathology (consistent with adenocarcinoma). Initiation of chemotherapy initially delayed in setting of acute medical conditions. Once medically stable, goals of care conversation was held with patient and family. Patient clearly expressed that he wished to forgo cancer-directed treatment and wanted to be discharge home with hospice. His code status was changed to DNR/DNI, CMO. CHRONIC ISSUES: =============== # PV thrombosis Prevoiously on SC enoxaparin, held in the setting of active GI bleed. Once hemoglobin stabilized, planned on re-starting; however, patient transitioned to CMO and AC deferred. # HTN Home antihypertensives initially held in the setting of shock. Once hemodynamically stable, blood pressure was within normal limits and did not require treatment. # Depression/Anxiety Continues home sertraline. TRANSITIONAL ISSUES: ==================== [] discharged DNR/DNI, CMO w/ home hospice ([MASKED] hospice) [] taking augmentin to complete 14 day course (last day [MASKED] for presumed cholangitis [] If issues with PTBD drains, consider follow-up with [MASKED], if for comfort and within [MASKED] [] Found to have incidental 2cm adrenal adeonoma. Per guidelines, consider repeat imaging in [MASKED] months (however, not within [MASKED] given transition to CMO) [] Has positive Hep C Ab with negative viral load. Not within [MASKED] to follow-up. #CODE: DNR/DNI, CMO (confirmed with MOLST in chart) #CONTACT: [MASKED] (partner/HCP): [MASKED] [MASKED] on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 3. Sertraline 100 mg PO DAILY 4. Enoxaparin Sodium 110 mg SC Q12H 5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings 6. Nicotine Patch 21 mg TD DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. ALPRAZolam 1 mg PO TID:PRN Anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 3. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet Refills:*0 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Fentanyl Patch 100 mcg/h TD Q72H RX *fentanyl 100 mcg/hour apply patch to arm q72hrs Disp #*2 Patch Refills:*0 6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate RX *hydromorphone 4 mg 1 tablet(s) by mouth q3hrs Disp #*20 Tablet Refills:*0 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB and wheezing 8. Lidocaine 5% Patch 2 PTCH TD QAM RX *lidocaine [Lidocare] 4 % Apply one patch to back qam Disp #*15 Patch Refills:*0 9. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all dressing changes 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet Refills:*0 11. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 12. Senna 8.6 mg PO DAILY:PRN constipation 13. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings 14. Nicotine Patch 21 mg TD DAILY 15. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: - Septic shock secondary to cholangitis - Acute kidney injury - Upper GI bleed Secondary diagnosis: - Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], Why were you admitted to the hospital? - You were transferred to [MASKED] from [MASKED] because you had an infection that made you extremely sick and confused, requiring an ICU level of care. What was done for you in the hospital? - Your kidneys were extremely damaged, so you received treatment to help improve your kidney function. - You had bleeding in your GI tract and received blood products to support you. You had a procedure to determine the cause of your bleeding. - You had an infection in the gallbladder system, so you received antibiotics. - Your cancer compressed your gallbladder system, so you had a procedure to decompress the area and stents placed to open up the blockages. - You received pain medications for your stomach pain. - You made the decision to transition to comfort-directed care. What should you do when you leave the hospital? - You should continue taking all medications that improve your comfort. - You should call your doctors with any questions or concerns you have. It was a pleasure taking care of you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "J9601", "N179", "E872", "Z515", "Z66", "I10", "F329", "F419", "Z86718" ]
[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "J9601: Acute respiratory failure with hypoxia", "K830: Cholangitis", "N179: Acute kidney failure, unspecified", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E872: Acidosis", "K831: Obstruction of bile duct", "I8500: Esophageal varices without bleeding", "C259: Malignant neoplasm of pancreas, unspecified", "E875: Hyperkalemia", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "D3500: Benign neoplasm of unspecified adrenal gland", "K209: Esophagitis, unspecified", "K2980: Duodenitis without bleeding", "G893: Neoplasm related pain (acute) (chronic)" ]
10,058,150
23,585,194
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old woman with DMII, HTN, HLD, depression/anxiety who presented to the ED after one episode of syncope that lasted minutes in duration while she was eating at a restaurant with family. The patient reports sitting at the table eating with family members when she spontaneously lost consciousness without dizziness or any other prodrome. She denies any other symptoms that she has experienced in recent days. The patient does report decreased PO intake during the days prior to her presentation. No fevers, malaise, cough, N/V, abdominal pain, changes in urination, leg pain, leg swelling. She denies a recent travel history or recent prolonged periods of immobility. There is no evidence that she became incontinent during the syncope event. Past Medical History: Past Medical History -DM -HTN -Hyperlipidemia -Depression -Anxiety -right hip trochanteric bursitis/gluteus medius tendinosis -lumbar spinal stenosis Social History: ___ Family History: No pertinent cardiac history or sudden cardiac death. Physical Exam: Admission Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 98.2 158/88 105 18 100%RA GENERAL: Pleasant, well appearing Hispanic female. ___ only in NAD. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: irregularly irregular. Normal S1, S2. ___ SEM at LUSB. JVP low LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Normal coordination. Gait assessment deferred Discharge Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 97.6 130/60 64 18 100%RA Exam: GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, HEART - RRR, nl S1-S2, no significant murmur appreciated LUNGS - CTAB ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c, no edema, 2+ DP pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Labs on Admission = = = = = = = = = = = ================================================================ ___ 07:30PM BLOOD WBC-8.6 RBC-4.26 Hgb-11.7 Hct-39.9 MCV-94 MCH-27.5 MCHC-29.3* RDW-13.6 RDWSD-46.5* Plt ___ ___ 07:30PM BLOOD Neuts-53.5 ___ Monos-9.1 Eos-2.1 Baso-0.8 Im ___ AbsNeut-4.61 AbsLymp-2.90 AbsMono-0.78 AbsEos-0.18 AbsBaso-0.07 ___ 07:30PM BLOOD ___ PTT-35.4 ___ ___ 07:30PM BLOOD Plt ___ ___ 07:30PM BLOOD Glucose-146* UreaN-18 Creat-1.8* Na-134 K-3.8 Cl-96 HCO3-15* AnGap-27* ___ 07:30PM BLOOD ALT-11 AST-14 TotBili-0.3 ___ 07:30PM BLOOD Lipase-66* ___ 07:30PM BLOOD proBNP-2689* ___ 07:30PM BLOOD cTropnT-<0.01 ___ 04:29AM BLOOD cTropnT-<0.01 ___ 07:30PM BLOOD Albumin-4.3 Calcium-11.2* Phos-2.8 Mg-1.5* ___ 07:30PM BLOOD D-Dimer-1365* ___ 11:10PM BLOOD Osmolal-305 ___ 07:30PM BLOOD TSH-4.7* ___ 07:30PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:41PM BLOOD Lactate-9.1* ___ 11:09PM BLOOD Lactate-5.7* Discharge Lab Results = = = = = = = = = = = ================================================================ ___ 05:16AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.0* Hct-32.6* MCV-90 MCH-27.6 MCHC-30.7* RDW-13.7 RDWSD-44.7 Plt ___ ___ 05:16AM BLOOD Plt ___ ___ 05:16AM BLOOD ___ PTT-69.8* ___ ___ 01:10PM BLOOD Na-133 K-5.3* Cl-99 ___ 05:16AM BLOOD Glucose-332* UreaN-22* Creat-1.5* Na-132* K-4.5 Cl-98 HCO3-23 AnGap-16 ___ 05:16AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 ___ 04:29AM BLOOD PTH-80* ___ 04:29AM BLOOD 25VitD-33 ___ 04:43AM BLOOD ___ pO2-106* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 ___ 04:43AM BLOOD Lactate-1.7 ECHO ___ EF=65% IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. CTA ___. No evidence of pulmonary embolism or aortic abnormality. 2. Dilated main pulmonary arteries suggestive of pulmonary artery hypertension. 3. Although this exam is not tailored for the evaluation of the airways note is made of anterior motion of the posterior membrane of the trachea and narrowing of the left mainstem and right bronchus intermedius which can be seen in the setting of tracheobronchial malacia. 4. Cholelithiasis Brief Hospital Course: ___ female w/PMH significant for HTN, DM, HLD, depression/anxiety who presents by EMS for syncope thought to be due to orthostatic hypotension ___ poor PO intake. # Syncope: Possible etiologies explaining her syncope include neurologic, cardiogenic, and orthostatic. Patient interview and collateral story from family members did not suggest any seizure activity at the time of the syncope and was most consistent with vasovagal event. TTE did not reveal AS, and EKG was notable for sinus rhythm with RBBB and frequent PACs which was unchanged from prior EKGs ___ years ago (provided by PCP's office). The patient was orthostatic upon arrival to the floor, even after receiving 1 liter on IVFs in the ED. The patient was given another liter O/N into hospital day 2. Her orthostatics improved by the time she was discharged such that she was no longer orthostatic with ambulation. Given the patient's RBBB appreciated on EKG in the ED and her syncope, a ddimer was ordered and found to be elevated. Without a another plausible explanation for an elevated ddimer, a PE was ruled out. A V/Q scan was attempted before giving the patient IV contrast, however the results were inconclusive due to inadequate inspiration so a CTA was pursued. The patient was hydrated with IV fluids prior to the start of the study per protocol given her CKD. CTA did not show PE. # Tachycardia: The patient was found to be tachycardic in the ED. This was likely a result of hypovolemia. EKG in the ED was read as AFib with RVR, however subsequent examination with additional EKGs and comparison with prior EKGs suggest the patient has stable sinus rythym with PACs. The RBBB was also stable from prior EKGs. The patient's atenolol was stopped given its dependence on renal clearance and the patient was started on metoprolol. She was monitored on telemetry without evidence of afib or other arrythmia. #CKD: Her baseline Cr is 1.4-1.6 with a GFR of 27. She was given IV fluids before CTA chest per protocol to protect her renal function. She was treated with her home valsartan throughout her hospital stay. At discharge her Cr was stable at 1.5. #hypercalcemia: The patient was admitted with a Ca of 11.2. With an elevated PTH, this would most consistent with primary hyperparathyroidism. Given the patient was not symptomatic during this hospitalization, further workup deferred to the outpatient setting. #Hyperkalemia: The patient was noted to have potassium of 5.3 prior to discharge without EKG changes, likely related to holding Lasix for orthostasis. The patient should have this repeated on ___ at her follow up appointment with her PCP. Her home lasix was restarted upon discharge. # Anion Gap metabolic acidosis: The patient was admitted with an anion gap of 23 in setting of elevated lactate. The patient's home medication list included metformin thus acidosis may have been due to metformin use in addition to global hypoperfusion related to syncope as above. The patient had evidence of DKA at admission and no evidence of uremia on exam, although patient has CKD, as above. The patient also came in with a positive EtOH on serum tox. Her VBG was relatively benign, not significant for alkalosis or acidosis. And her serum osm gap was only 10.37 suggesting against ingestion. Her metformin was stopped on this admission and at discharge. #HTN: Her hypertension was controlled using her home doses of valsartan and amlodipine. She was switched from atenolol to metoprolol given her CKD. Her furosemide was initially held and restarted at discharge. #DM: The patient's last A1c was 9.4 in ___. She is on Levemir 30U daily at home. Patient was not clear on her dosing initially and received OMR dosing of 35u BID of glargine with occasional lows into the ___. Per further discussion with patient, she was started back on 30u long acting insulin (levemir) as she stated she never took BID dosing, she should continue taking insulin as she has been at home. ============================= Transitional Issues ============================= [] Please repeat sodium, potassium and glucose at PCP on ___ ___. Na 133 on discharge with K of 5.3 (likely from holding Lasix for orthostasis) [] switched patient from atenolol to metoprolol 50mg PO extended release [] stopped metformin given lactic acidosis on presentation [] Noted to have hypercalcemia with elevated PTH on admission. Please trend calcium as outpatient and consider further work-up if persistent. Calcium and vitamin D held on discharge given hypercalcemia []TSH elevated to 4.7 on admission. Consider repeat TSH in 6 weeks to evaluate for hypothyroidism [] Ongoing medication education, assistance with administration # CONTACT: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Valsartan 320 mg PO DAILY 3. Gabapentin 100 mg PO BID 4. Atenolol 100 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Alendronate Sodium 70 mg PO Frequency is Unknown 7. Amlodipine 10 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Levemir 30 Units Breakfast 10. Furosemide 20 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Fluticasone Propionate 110mcg 1 PUFF IH BID 13. Cilostazol 100 mg PO BID 14. Omeprazole 20 mg PO DAILY 15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 16. Aspirin 81 mg PO DAILY 17. Sertraline 50 mg PO DAILY 18. GlipiZIDE 10 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Cilostazol 100 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Gabapentin 100 mg PO BID 8. Levemir 30 Units Breakfast 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet by mouth Daily Disp #*30 Tablet Refills:*0 14. Alendronate Sodium 70 mg PO QTHUR 15. GlipiZIDE 10 mg PO BID 16. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: syncope likely secondary to orthostasis Lactic Acidosis Sinus tachycardia Hypercalcemia Hyponatremia 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 ___ after you lost consciousness while eating dinner with family. You were evaluated to determine the cause of your loss of consciousness. You heart was examined and it had normal rhythm and normal contractile function. You were not found to have a blood clot in the lungs. The most likely cuase of your loss of consciousness is dehydration and decreased intake of food and liquid prior to the event. Your symptoms of dehydration improved with fluids in the hospital. You were also noted to have a low sodium level in your blood. This was likely from fluids that you received in the hospital. You will need to get your blood sodium level checked at your PCP's office on ___. You were also found to have an elevated blood calcium level. It is important that you stop taking your calcium and vitamin D supplements for now until you follow-up with your primary care physician. For your diabetes, we have stopped one of your oral medications called metformin because this can cause elevated lactate levels due to your poor kidney function. Please STOP taking metformin when you return home. Finally, for your blood pressure, we stopped atenolol and started metoprolol which is better for patients with kidney disease. Please continue to take all of your medications as prescribed below. It was a pleasure taking care of you. Your ___ Care Team Followup Instructions: ___
[ "E860", "E872", "N184", "E119", "I129", "D649", "E871", "E785", "I4510", "E210", "I491", "E875", "Z794", "R7989", "F329", "F419", "I890" ]
Allergies: Penicillins Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a [MASKED] year old woman with DMII, HTN, HLD, depression/anxiety who presented to the ED after one episode of syncope that lasted minutes in duration while she was eating at a restaurant with family. The patient reports sitting at the table eating with family members when she spontaneously lost consciousness without dizziness or any other prodrome. She denies any other symptoms that she has experienced in recent days. The patient does report decreased PO intake during the days prior to her presentation. No fevers, malaise, cough, N/V, abdominal pain, changes in urination, leg pain, leg swelling. She denies a recent travel history or recent prolonged periods of immobility. There is no evidence that she became incontinent during the syncope event. Past Medical History: Past Medical History -DM -HTN -Hyperlipidemia -Depression -Anxiety -right hip trochanteric bursitis/gluteus medius tendinosis -lumbar spinal stenosis Social History: [MASKED] Family History: No pertinent cardiac history or sudden cardiac death. Physical Exam: Admission Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 98.2 158/88 105 18 100%RA GENERAL: Pleasant, well appearing Hispanic female. [MASKED] only in NAD. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: irregularly irregular. Normal S1, S2. [MASKED] SEM at LUSB. JVP low LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN [MASKED] grossly intact. Preserved sensation throughout. [MASKED] strength throughout. [MASKED] reflexes, equal [MASKED]. Normal coordination. Gait assessment deferred Discharge Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 97.6 130/60 64 18 100%RA Exam: GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, HEART - RRR, nl S1-S2, no significant murmur appreciated LUNGS - CTAB ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c, no edema, 2+ DP pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Labs on Admission = = = = = = = = = = = ================================================================ [MASKED] 07:30PM BLOOD WBC-8.6 RBC-4.26 Hgb-11.7 Hct-39.9 MCV-94 MCH-27.5 MCHC-29.3* RDW-13.6 RDWSD-46.5* Plt [MASKED] [MASKED] 07:30PM BLOOD Neuts-53.5 [MASKED] Monos-9.1 Eos-2.1 Baso-0.8 Im [MASKED] AbsNeut-4.61 AbsLymp-2.90 AbsMono-0.78 AbsEos-0.18 AbsBaso-0.07 [MASKED] 07:30PM BLOOD [MASKED] PTT-35.4 [MASKED] [MASKED] 07:30PM BLOOD Plt [MASKED] [MASKED] 07:30PM BLOOD Glucose-146* UreaN-18 Creat-1.8* Na-134 K-3.8 Cl-96 HCO3-15* AnGap-27* [MASKED] 07:30PM BLOOD ALT-11 AST-14 TotBili-0.3 [MASKED] 07:30PM BLOOD Lipase-66* [MASKED] 07:30PM BLOOD proBNP-2689* [MASKED] 07:30PM BLOOD cTropnT-<0.01 [MASKED] 04:29AM BLOOD cTropnT-<0.01 [MASKED] 07:30PM BLOOD Albumin-4.3 Calcium-11.2* Phos-2.8 Mg-1.5* [MASKED] 07:30PM BLOOD D-Dimer-1365* [MASKED] 11:10PM BLOOD Osmolal-305 [MASKED] 07:30PM BLOOD TSH-4.7* [MASKED] 07:30PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 07:41PM BLOOD Lactate-9.1* [MASKED] 11:09PM BLOOD Lactate-5.7* Discharge Lab Results = = = = = = = = = = = ================================================================ [MASKED] 05:16AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.0* Hct-32.6* MCV-90 MCH-27.6 MCHC-30.7* RDW-13.7 RDWSD-44.7 Plt [MASKED] [MASKED] 05:16AM BLOOD Plt [MASKED] [MASKED] 05:16AM BLOOD [MASKED] PTT-69.8* [MASKED] [MASKED] 01:10PM BLOOD Na-133 K-5.3* Cl-99 [MASKED] 05:16AM BLOOD Glucose-332* UreaN-22* Creat-1.5* Na-132* K-4.5 Cl-98 HCO3-23 AnGap-16 [MASKED] 05:16AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 [MASKED] 04:29AM BLOOD PTH-80* [MASKED] 04:29AM BLOOD 25VitD-33 [MASKED] 04:43AM BLOOD [MASKED] pO2-106* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [MASKED] 04:43AM BLOOD Lactate-1.7 ECHO [MASKED] EF=65% IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. CTA [MASKED]. No evidence of pulmonary embolism or aortic abnormality. 2. Dilated main pulmonary arteries suggestive of pulmonary artery hypertension. 3. Although this exam is not tailored for the evaluation of the airways note is made of anterior motion of the posterior membrane of the trachea and narrowing of the left mainstem and right bronchus intermedius which can be seen in the setting of tracheobronchial malacia. 4. Cholelithiasis Brief Hospital Course: [MASKED] female w/PMH significant for HTN, DM, HLD, depression/anxiety who presents by EMS for syncope thought to be due to orthostatic hypotension [MASKED] poor PO intake. # Syncope: Possible etiologies explaining her syncope include neurologic, cardiogenic, and orthostatic. Patient interview and collateral story from family members did not suggest any seizure activity at the time of the syncope and was most consistent with vasovagal event. TTE did not reveal AS, and EKG was notable for sinus rhythm with RBBB and frequent PACs which was unchanged from prior EKGs [MASKED] years ago (provided by PCP's office). The patient was orthostatic upon arrival to the floor, even after receiving 1 liter on IVFs in the ED. The patient was given another liter O/N into hospital day 2. Her orthostatics improved by the time she was discharged such that she was no longer orthostatic with ambulation. Given the patient's RBBB appreciated on EKG in the ED and her syncope, a ddimer was ordered and found to be elevated. Without a another plausible explanation for an elevated ddimer, a PE was ruled out. A V/Q scan was attempted before giving the patient IV contrast, however the results were inconclusive due to inadequate inspiration so a CTA was pursued. The patient was hydrated with IV fluids prior to the start of the study per protocol given her CKD. CTA did not show PE. # Tachycardia: The patient was found to be tachycardic in the ED. This was likely a result of hypovolemia. EKG in the ED was read as AFib with RVR, however subsequent examination with additional EKGs and comparison with prior EKGs suggest the patient has stable sinus rythym with PACs. The RBBB was also stable from prior EKGs. The patient's atenolol was stopped given its dependence on renal clearance and the patient was started on metoprolol. She was monitored on telemetry without evidence of afib or other arrythmia. #CKD: Her baseline Cr is 1.4-1.6 with a GFR of 27. She was given IV fluids before CTA chest per protocol to protect her renal function. She was treated with her home valsartan throughout her hospital stay. At discharge her Cr was stable at 1.5. #hypercalcemia: The patient was admitted with a Ca of 11.2. With an elevated PTH, this would most consistent with primary hyperparathyroidism. Given the patient was not symptomatic during this hospitalization, further workup deferred to the outpatient setting. #Hyperkalemia: The patient was noted to have potassium of 5.3 prior to discharge without EKG changes, likely related to holding Lasix for orthostasis. The patient should have this repeated on [MASKED] at her follow up appointment with her PCP. Her home lasix was restarted upon discharge. # Anion Gap metabolic acidosis: The patient was admitted with an anion gap of 23 in setting of elevated lactate. The patient's home medication list included metformin thus acidosis may have been due to metformin use in addition to global hypoperfusion related to syncope as above. The patient had evidence of DKA at admission and no evidence of uremia on exam, although patient has CKD, as above. The patient also came in with a positive EtOH on serum tox. Her VBG was relatively benign, not significant for alkalosis or acidosis. And her serum osm gap was only 10.37 suggesting against ingestion. Her metformin was stopped on this admission and at discharge. #HTN: Her hypertension was controlled using her home doses of valsartan and amlodipine. She was switched from atenolol to metoprolol given her CKD. Her furosemide was initially held and restarted at discharge. #DM: The patient's last A1c was 9.4 in [MASKED]. She is on Levemir 30U daily at home. Patient was not clear on her dosing initially and received OMR dosing of 35u BID of glargine with occasional lows into the [MASKED]. Per further discussion with patient, she was started back on 30u long acting insulin (levemir) as she stated she never took BID dosing, she should continue taking insulin as she has been at home. ============================= Transitional Issues ============================= [] Please repeat sodium, potassium and glucose at PCP on [MASKED] [MASKED]. Na 133 on discharge with K of 5.3 (likely from holding Lasix for orthostasis) [] switched patient from atenolol to metoprolol 50mg PO extended release [] stopped metformin given lactic acidosis on presentation [] Noted to have hypercalcemia with elevated PTH on admission. Please trend calcium as outpatient and consider further work-up if persistent. Calcium and vitamin D held on discharge given hypercalcemia []TSH elevated to 4.7 on admission. Consider repeat TSH in 6 weeks to evaluate for hypothyroidism [] Ongoing medication education, assistance with administration # CONTACT: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Valsartan 320 mg PO DAILY 3. Gabapentin 100 mg PO BID 4. Atenolol 100 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Alendronate Sodium 70 mg PO Frequency is Unknown 7. Amlodipine 10 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Levemir 30 Units Breakfast 10. Furosemide 20 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Fluticasone Propionate 110mcg 1 PUFF IH BID 13. Cilostazol 100 mg PO BID 14. Omeprazole 20 mg PO DAILY 15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 16. Aspirin 81 mg PO DAILY 17. Sertraline 50 mg PO DAILY 18. GlipiZIDE 10 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Cilostazol 100 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Gabapentin 100 mg PO BID 8. Levemir 30 Units Breakfast 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet by mouth Daily Disp #*30 Tablet Refills:*0 14. Alendronate Sodium 70 mg PO QTHUR 15. GlipiZIDE 10 mg PO BID 16. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: syncope likely secondary to orthostasis Lactic Acidosis Sinus tachycardia Hypercalcemia Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] after you lost consciousness while eating dinner with family. You were evaluated to determine the cause of your loss of consciousness. You heart was examined and it had normal rhythm and normal contractile function. You were not found to have a blood clot in the lungs. The most likely cuase of your loss of consciousness is dehydration and decreased intake of food and liquid prior to the event. Your symptoms of dehydration improved with fluids in the hospital. You were also noted to have a low sodium level in your blood. This was likely from fluids that you received in the hospital. You will need to get your blood sodium level checked at your PCP's office on [MASKED]. You were also found to have an elevated blood calcium level. It is important that you stop taking your calcium and vitamin D supplements for now until you follow-up with your primary care physician. For your diabetes, we have stopped one of your oral medications called metformin because this can cause elevated lactate levels due to your poor kidney function. Please STOP taking metformin when you return home. Finally, for your blood pressure, we stopped atenolol and started metoprolol which is better for patients with kidney disease. Please continue to take all of your medications as prescribed below. It was a pleasure taking care of you. Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E872", "E119", "I129", "D649", "E871", "E785", "Z794", "F329", "F419" ]
[ "E860: Dehydration", "E872: Acidosis", "N184: Chronic kidney disease, stage 4 (severe)", "E119: Type 2 diabetes mellitus without complications", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D649: Anemia, unspecified", "E871: Hypo-osmolality and hyponatremia", "E785: Hyperlipidemia, unspecified", "I4510: Unspecified right bundle-branch block", "E210: Primary hyperparathyroidism", "I491: Atrial premature depolarization", "E875: Hyperkalemia", "Z794: Long term (current) use of insulin", "R7989: Other specified abnormal findings of blood chemistry", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I890: Lymphedema, not elsewhere classified" ]
10,058,305
22,602,600
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 lower extremity foot drop and numbness Major Surgical or Invasive Procedure: L4-S1 laminectomy and fusion on ___ with Dr. ___ ___ of Present Illness: ___ is a pleasant ___ lady who is seen today with complaints of acute onset left-sided footdrop and numbness since last 1 month. She has been diagnosed of severe right hip arthritis with severe restriction of the hip range of motion. She has significant difficulty in mobilization because of the hip and her mobility has significantly decreased since last month because of the foot issue and she feels that she is unstable because of the left foot. Her examination shows are ___ strength in her ___ tibialis anterior and gastrosoleus in the left side. She had L5 and S1 dermatomal numbness. Her radiographs show grade 2 L5-S1 lytic spondylolisthesis without any instability. Her MRI shows severe L5-S1 bilateral foraminal stenosis with bilateral lateral recess stenosis. Past Medical History: Past medical history is positive for heart disease in the form of cardiomyopathy, high blood pressure, diabetes Past surgical history is positive for cholecystectomy, appendectomy, left leg vein removal, skin graft from left foot, cataracts and left hip replacement Social History: ___ Family History: Family history is positive for cancer diabetes and heart disease Physical Exam: Last 24h:NAE's overnight. Cleared by ___ for discharge to REHAB. HVAC scant drainage. PE: VS 99.8 PO 113 / 68 75 16 93 Ra NAD, A&Ox4 nl resp effort RRR Incision c/d/I, well approximated, no erythema or drainage. dry dressing applied, HVAC drain removed. Sensory: ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 L 5 5 5 4 4 4 Clonus: No beats Labs: ___: WBC: a) 14.9*; b) 15.2* ___: HGB: a) 8.2*; b) 8.4* ___: HCT: a) 26.2*; b) 27.2* ___: Plt Count: a) 145*; b) 163 ___: Na: 142 (New reference range as of ___: K: 4.1 (New reference range as of ___: Cl: 103 ___: CO2: 25 ___: Glucose: 166* (If fasting, 70-100 normal, >125 provisional diabetes) ___: BUN: 16 ___: Creat: 0.8 Imaging:L-spine XR ___- IMPRESSION: Post lumbar fusion of L4 through S1 as described above with no evidence of acute hardware related complications. Pertinent Results: ___ 09:35AM BLOOD WBC-15.4* RBC-2.48* Hgb-7.9* Hct-24.8* MCV-100* MCH-31.9 MCHC-31.9* RDW-14.1 RDWSD-51.6* Plt ___ ___ 05:18PM BLOOD WBC-14.9* RBC-2.59* Hgb-8.2* Hct-26.2* MCV-101* MCH-31.7 MCHC-31.3* RDW-14.2 RDWSD-52.4* Plt ___ ___ 06:10AM BLOOD WBC-15.2* RBC-2.66* Hgb-8.4* Hct-27.2* MCV-102* MCH-31.6 MCHC-30.9* RDW-14.0 RDWSD-52.1* Plt ___ ___ 09:35AM BLOOD Plt ___ ___ 05:18PM BLOOD Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 09:35AM BLOOD Glucose-114* UreaN-19 Creat-0.8 Na-139 K-3.5 Cl-101 HCO3-25 AnGap-13 ___ 06:10AM BLOOD Glucose-166* UreaN-16 Creat-0.8 Na-142 K-4.1 Cl-103 HCO3-25 AnGap-14 ___ 09:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 ___ 06:10AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.7 Brief Hospital Course: Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable ___ were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Metoprolol Tartrate 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Naproxen 250 mg PO Q8H:PRN Pain - Moderate 5. Cyanocobalamin 1000 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 5. Allopurinol ___ mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Cyanocobalamin 1000 mcg PO DAILY 8. Metoprolol Tartrate 25 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Lumbar spinal stenosis L5-S1. 2. L5-S1 grade I-II isthmic/lytic spondylolisthesis. 3. Right lower extremity radiculopathy with foot drop. 4. Lumbar degenerative disc disease. 5. Likely osteoporosis. 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:1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on ___.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision,take baseline X-rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Dry dressing daily until your follow up appointment.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. Followup Instructions: ___
[ "M4807", "I429", "M48061", "M4316", "M4317", "M21372", "M5116", "R200", "M1611", "I10", "E785", "E119", "Z96642", "Z961", "M810" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left lower extremity foot drop and numbness Major Surgical or Invasive Procedure: L4-S1 laminectomy and fusion on [MASKED] with Dr. [MASKED] [MASKED] of Present Illness: [MASKED] is a pleasant [MASKED] lady who is seen today with complaints of acute onset left-sided footdrop and numbness since last 1 month. She has been diagnosed of severe right hip arthritis with severe restriction of the hip range of motion. She has significant difficulty in mobilization because of the hip and her mobility has significantly decreased since last month because of the foot issue and she feels that she is unstable because of the left foot. Her examination shows are [MASKED] strength in her [MASKED] tibialis anterior and gastrosoleus in the left side. She had L5 and S1 dermatomal numbness. Her radiographs show grade 2 L5-S1 lytic spondylolisthesis without any instability. Her MRI shows severe L5-S1 bilateral foraminal stenosis with bilateral lateral recess stenosis. Past Medical History: Past medical history is positive for heart disease in the form of cardiomyopathy, high blood pressure, diabetes Past surgical history is positive for cholecystectomy, appendectomy, left leg vein removal, skin graft from left foot, cataracts and left hip replacement Social History: [MASKED] Family History: Family history is positive for cancer diabetes and heart disease Physical Exam: Last 24h:NAE's overnight. Cleared by [MASKED] for discharge to REHAB. HVAC scant drainage. PE: VS 99.8 PO 113 / 68 75 16 93 Ra NAD, A&Ox4 nl resp effort RRR Incision c/d/I, well approximated, no erythema or drainage. dry dressing applied, HVAC drain removed. Sensory: [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 L 5 5 5 4 4 4 Clonus: No beats Labs: [MASKED]: WBC: a) 14.9*; b) 15.2* [MASKED]: HGB: a) 8.2*; b) 8.4* [MASKED]: HCT: a) 26.2*; b) 27.2* [MASKED]: Plt Count: a) 145*; b) 163 [MASKED]: Na: 142 (New reference range as of [MASKED]: K: 4.1 (New reference range as of [MASKED]: Cl: 103 [MASKED]: CO2: 25 [MASKED]: Glucose: 166* (If fasting, 70-100 normal, >125 provisional diabetes) [MASKED]: BUN: 16 [MASKED]: Creat: 0.8 Imaging:L-spine XR [MASKED]- IMPRESSION: Post lumbar fusion of L4 through S1 as described above with no evidence of acute hardware related complications. Pertinent Results: [MASKED] 09:35AM BLOOD WBC-15.4* RBC-2.48* Hgb-7.9* Hct-24.8* MCV-100* MCH-31.9 MCHC-31.9* RDW-14.1 RDWSD-51.6* Plt [MASKED] [MASKED] 05:18PM BLOOD WBC-14.9* RBC-2.59* Hgb-8.2* Hct-26.2* MCV-101* MCH-31.7 MCHC-31.3* RDW-14.2 RDWSD-52.4* Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-15.2* RBC-2.66* Hgb-8.4* Hct-27.2* MCV-102* MCH-31.6 MCHC-30.9* RDW-14.0 RDWSD-52.1* Plt [MASKED] [MASKED] 09:35AM BLOOD Plt [MASKED] [MASKED] 05:18PM BLOOD Plt [MASKED] [MASKED] 06:10AM BLOOD Plt [MASKED] [MASKED] 09:35AM BLOOD Glucose-114* UreaN-19 Creat-0.8 Na-139 K-3.5 Cl-101 HCO3-25 AnGap-13 [MASKED] 06:10AM BLOOD Glucose-166* UreaN-16 Creat-0.8 Na-142 K-4.1 Cl-103 HCO3-25 AnGap-14 [MASKED] 09:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 [MASKED] 06:10AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.7 Brief Hospital Course: Patient was admitted to the [MASKED] Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable [MASKED] were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Metoprolol Tartrate 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Naproxen 250 mg PO Q8H:PRN Pain - Moderate 5. Cyanocobalamin 1000 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 5. Allopurinol [MASKED] mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Cyanocobalamin 1000 mcg PO DAILY 8. Metoprolol Tartrate 25 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: 1. Lumbar spinal stenosis L5-S1. 2. L5-S1 grade I-II isthmic/lytic spondylolisthesis. 3. Right lower extremity radiculopathy with foot drop. 4. Lumbar degenerative disc disease. 5. Likely osteoporosis. 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:1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on [MASKED].We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision,take baseline X-rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Dry dressing daily until your follow up appointment.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. Followup Instructions: [MASKED]
[]
[ "I10", "E785", "E119" ]
[ "M4807: Spinal stenosis, lumbosacral region", "I429: Cardiomyopathy, unspecified", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "M4316: Spondylolisthesis, lumbar region", "M4317: Spondylolisthesis, lumbosacral region", "M21372: Foot drop, left foot", "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "R200: Anesthesia of skin", "M1611: Unilateral primary osteoarthritis, right hip", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z96642: Presence of left artificial hip joint", "Z961: Presence of intraocular lens", "M810: Age-related osteoporosis without current pathological fracture" ]
10,058,341
22,465,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: oxycodone Attending: ___. Chief Complaint: LUE DVT - here for first rib resection Major Surgical or Invasive Procedure: Left 1st rib resection History of Present Illness: This patient is a ___ woman, with a history of left subclavian occlusion. She underwent venous lysis and was noted to have occlusion at the junction of the 1st rib and the clavicle. She is now taken to the operating room for resection of 1st rib to decompress the vein. The procedure and risks were explained to the patient. She understood and wished to proceed. Past Medical History: DVT in LUE s/p thrombolysis and balloon angioplasy Social History: ___ Family History: N/C Physical Exam: Physical Exam: Vital Signs: T: 98.1F HR: 65 BP: 92/57 RR: 16 O2: 98% RA General: NAD, comfortable HEENT: No scleral icterus, mucus membranes moist, EOMI, PERRLA CV: RRR, no M/R/G PULM: Clear to auscultation b/l, no W/R/R ABD: Soft, nontender, nondistended, no rebound tenderness or guarding. Normoactive bowel sounds. EXT: left shoulder incision C/D/I, JP drain serosanguinous Vascular: R:p/p/p/p L: p/p/p/p, palpable radial/ulnar bilaterally Pertinent Results: Labs: ___ 06:40AM BLOOD WBC-9.2 RBC-4.11 Hgb-12.6 Hct-39.4 MCV-96 MCH-30.7 MCHC-32.0 RDW-12.7 RDWSD-44.4 Plt ___ ___ 07:00AM BLOOD WBC-12.9* RBC-4.06 Hgb-12.5 Hct-38.0 MCV-94 MCH-30.8 MCHC-32.9 RDW-12.3 RDWSD-42.5 Plt ___ ___ 04:03PM BLOOD WBC-14.1*# RBC-4.33 Hgb-13.2 Hct-39.7 MCV-92 MCH-30.5 MCHC-33.2 RDW-12.4 RDWSD-42.1 Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 04:03PM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-141 K-4.7 Cl-105 HCO3-22 AnGap-19 ___ 07:00AM BLOOD Glucose-101* UreaN-6 Creat-0.5 Na-140 K-4.2 Cl-107 HCO3-21* AnGap-16 ___ 04:03PM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-138 K-4.0 Cl-106 HCO3-22 AnGap-14 ___ 04:03PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:40AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8 ___ 07:00AM BLOOD Phos-3.0 Mg-1.8 ___ 04:03PM BLOOD Calcium-8.7 Phos-2.4* Mg-1.7 ___ 04:03PM BLOOD TSH-0.43 Imaging: CHEST (PORTABLE AP) Study Date of ___ 12:55 ___ IMPRESSION: Heart size is normal. Mediastinum is stable. The left first rib appears to be resected. There is no definitive pneumothorax demonstrated but overlying structures might precluded from detection. No pleural effusion. No pulmonary edema. Brief Hospital Course: Ms. ___ was admitted to the hospital for left 1st rib resection following episode of venous thoracic outlet syndrome. In the pre-operative area the patient was noted to be bradycardic to the 40-50s at baseline. The patient was taken to the operating room and tolerated the procedure well, a JP drain was placed for monitoring. For full details of the procedure please see the operative report. Post-op CXR demonstrated expected post-operative findings, no pneumothorax or acute process. The drain was noted to be sanguinous in nature but the patient's Hct remained stable. The patient did have some mild nausea and bradycardia in the PACU without lightheadedness or dizziness. Electrolytes were repleted and an EKG demonstrated sinus bradycardia without other concerning features. Her blood pressure remained stable throughout this time with SBP 120s. Her pain was well-controlled with a dilaudid PCA. She was transferred to the VICU in stable condition. On POD1, she initially tolerated a regular diet but then had nausea w/ emesis. Her drain became more serosanguinous with ~140cc in output. Scopolamine and Zofran improved her nausea and she was later able to tolerate diet. She voided without issues. She worked with Occupation therapy on POD1 and was cleared for home. On POD2, she was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. The drain output was 40cc serosanguinous and the incision was C/D/I. She was deemed ready for discharge with the drain, and was given the appropriate discharge and follow-up instructions. She will see Dr. ___ in clinic in 1 week for drain removal, and she was discharged with Xarelto 20mg daily to take until her LUE venogram in 1 month. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 60 mg SC Q12H 2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 3. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every ___ hours Disp #*30 Tablet Refills:*0 2. Calcium Carbonate 500 mg PO QID:PRN heart burn/reflux RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 3. Rivaroxaban 20 mg PO DAILY RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every ___ hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Thoracic outlet syndrome - venous 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 ___. You were admitted for a left first rib resection because of clots forming in your vein due to rib compression. You have now recovered fully and are ready for discharge. You will have nursing services to help you take care of the shoulder drain, which will be removed on ___ in clinic. Please follow the below instructions for a safe and speedy recovery. Rib resection Discharge Instructions WHAT TO EXPECT: It is normal to have slight swelling of the affected arm: • It is very important to keep your arm as mobile as possible post-operative so that you do not develop a frozen shoulder, the only activity restriction is to NOT elevate your arm above your head until after your follow-up appointment. All other arm movements are encouraged • You will be discharged with a drain in the shoulder. Make sure to follow nursing instructions on emptying and recording daily drain output. Your drain will be removed at a clinic appointment next ___ • 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 What activities you can and cannot do: • You may shower (let the soapy water run over the shoulder 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 that is draining, as needed • No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow arm incision 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 MEDICATION: • Take Xarelto 20mg once daily until after your left arm venogram is completed in a month • 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 CALL THE OFFICE FOR: ___ • Numbness, coldness or pain in the effected extremity • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from incision site SUDDEN, SEVERE BLEEDING OR SWELLING in the effected arm • Sit down and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___
[ "G540", "I82B12", "Z7901", "F17210", "R112", "Y838", "Y92239" ]
Allergies: oxycodone Chief Complaint: LUE DVT - here for first rib resection Major Surgical or Invasive Procedure: Left 1st rib resection History of Present Illness: This patient is a [MASKED] woman, with a history of left subclavian occlusion. She underwent venous lysis and was noted to have occlusion at the junction of the 1st rib and the clavicle. She is now taken to the operating room for resection of 1st rib to decompress the vein. The procedure and risks were explained to the patient. She understood and wished to proceed. Past Medical History: DVT in LUE s/p thrombolysis and balloon angioplasy Social History: [MASKED] Family History: N/C Physical Exam: Physical Exam: Vital Signs: T: 98.1F HR: 65 BP: 92/57 RR: 16 O2: 98% RA General: NAD, comfortable HEENT: No scleral icterus, mucus membranes moist, EOMI, PERRLA CV: RRR, no M/R/G PULM: Clear to auscultation b/l, no W/R/R ABD: Soft, nontender, nondistended, no rebound tenderness or guarding. Normoactive bowel sounds. EXT: left shoulder incision C/D/I, JP drain serosanguinous Vascular: R:p/p/p/p L: p/p/p/p, palpable radial/ulnar bilaterally Pertinent Results: Labs: [MASKED] 06:40AM BLOOD WBC-9.2 RBC-4.11 Hgb-12.6 Hct-39.4 MCV-96 MCH-30.7 MCHC-32.0 RDW-12.7 RDWSD-44.4 Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-12.9* RBC-4.06 Hgb-12.5 Hct-38.0 MCV-94 MCH-30.8 MCHC-32.9 RDW-12.3 RDWSD-42.5 Plt [MASKED] [MASKED] 04:03PM BLOOD WBC-14.1*# RBC-4.33 Hgb-13.2 Hct-39.7 MCV-92 MCH-30.5 MCHC-33.2 RDW-12.4 RDWSD-42.1 Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 07:00AM BLOOD Plt [MASKED] [MASKED] 04:03PM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-141 K-4.7 Cl-105 HCO3-22 AnGap-19 [MASKED] 07:00AM BLOOD Glucose-101* UreaN-6 Creat-0.5 Na-140 K-4.2 Cl-107 HCO3-21* AnGap-16 [MASKED] 04:03PM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-138 K-4.0 Cl-106 HCO3-22 AnGap-14 [MASKED] 04:03PM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 06:40AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8 [MASKED] 07:00AM BLOOD Phos-3.0 Mg-1.8 [MASKED] 04:03PM BLOOD Calcium-8.7 Phos-2.4* Mg-1.7 [MASKED] 04:03PM BLOOD TSH-0.43 Imaging: CHEST (PORTABLE AP) Study Date of [MASKED] 12:55 [MASKED] IMPRESSION: Heart size is normal. Mediastinum is stable. The left first rib appears to be resected. There is no definitive pneumothorax demonstrated but overlying structures might precluded from detection. No pleural effusion. No pulmonary edema. Brief Hospital Course: Ms. [MASKED] was admitted to the hospital for left 1st rib resection following episode of venous thoracic outlet syndrome. In the pre-operative area the patient was noted to be bradycardic to the 40-50s at baseline. The patient was taken to the operating room and tolerated the procedure well, a JP drain was placed for monitoring. For full details of the procedure please see the operative report. Post-op CXR demonstrated expected post-operative findings, no pneumothorax or acute process. The drain was noted to be sanguinous in nature but the patient's Hct remained stable. The patient did have some mild nausea and bradycardia in the PACU without lightheadedness or dizziness. Electrolytes were repleted and an EKG demonstrated sinus bradycardia without other concerning features. Her blood pressure remained stable throughout this time with SBP 120s. Her pain was well-controlled with a dilaudid PCA. She was transferred to the VICU in stable condition. On POD1, she initially tolerated a regular diet but then had nausea w/ emesis. Her drain became more serosanguinous with ~140cc in output. Scopolamine and Zofran improved her nausea and she was later able to tolerate diet. She voided without issues. She worked with Occupation therapy on POD1 and was cleared for home. On POD2, she was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. The drain output was 40cc serosanguinous and the incision was C/D/I. She was deemed ready for discharge with the drain, and was given the appropriate discharge and follow-up instructions. She will see Dr. [MASKED] in clinic in 1 week for drain removal, and she was discharged with Xarelto 20mg daily to take until her LUE venogram in 1 month. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 60 mg SC Q12H 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 3. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every [MASKED] hours Disp #*30 Tablet Refills:*0 2. Calcium Carbonate 500 mg PO QID:PRN heart burn/reflux RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 3. Rivaroxaban 20 mg PO DAILY RX *rivaroxaban [[MASKED]] 20 mg 1 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every [MASKED] hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Thoracic outlet syndrome - venous 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]. You were admitted for a left first rib resection because of clots forming in your vein due to rib compression. You have now recovered fully and are ready for discharge. You will have nursing services to help you take care of the shoulder drain, which will be removed on [MASKED] in clinic. Please follow the below instructions for a safe and speedy recovery. Rib resection Discharge Instructions WHAT TO EXPECT: It is normal to have slight swelling of the affected arm: • It is very important to keep your arm as mobile as possible post-operative so that you do not develop a frozen shoulder, the only activity restriction is to NOT elevate your arm above your head until after your follow-up appointment. All other arm movements are encouraged • You will be discharged with a drain in the shoulder. Make sure to follow nursing instructions on emptying and recording daily drain output. Your drain will be removed at a clinic appointment next [MASKED] • 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 What activities you can and cannot do: • You may shower (let the soapy water run over the shoulder 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 that is draining, as needed • No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow arm incision 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 MEDICATION: • Take Xarelto 20mg once daily until after your left arm venogram is completed in a month • 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 CALL THE OFFICE FOR: [MASKED] • Numbness, coldness or pain in the effected extremity • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from incision site SUDDEN, SEVERE BLEEDING OR SWELLING in the effected arm • Sit down and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [MASKED]. If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. Followup Instructions: [MASKED]
[]
[ "Z7901", "F17210" ]
[ "G540: Brachial plexus disorders", "I82B12: Acute embolism and thrombosis of left subclavian vein", "Z7901: Long term (current) use of anticoagulants", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R112: Nausea with vomiting, 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" ]
10,058,341
26,863,120
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: LUE arm swelling, pain Major Surgical or Invasive Procedure: ___: thrombolysis of LUE DVT 1. Real-time ultrasound-guided access to the left basilic vein and placement of a ___ sheath. 2. Selective catheterization of the SVC, ___ order vessel. 3. Left upper extremity venogram. 4. Placement of a 20 cm ___ catheter within the left subclavian vein thrombus. ___: lysis catheter check, removal 1. Lysis check following overnight thrombolysis. 2. Left upper extremity venogram. 3. tPA Angiojet thrombectomy. 4. Balloon angioplasty of the left subclavian vein with a 6 mm balloon. History of Present Illness: ___ woman with no significant past medical history who presented with left upper extremity swelling and was found to have an extensive left subclavian DVT, thought to be secondary to venous thoracic outlet syndrome. Past Medical History: N/A Social History: ___ Family History: N/C Physical Exam: DISCHARGE EXAM: T98.5, HR68, BP91/54, RR 16 96%RA GEN: NAD, AOx3, pleasant CV: RRR PULM: breathing comfortably on room air GI: abdomen soft, NT, ND EXT: LUE swelling decreased, access site clean and dry with minimal ecchymosis, no evidence of hematoma; palpable radial and ulnar pulses; motor/sensory grossly intact Pertinent Results: DISCHARGE LABS: ___ 08:50AM BLOOD WBC-8.3 RBC-4.04 Hgb-12.2 Hct-37.0 MCV-92 MCH-30.2 MCHC-33.0 RDW-12.3 RDWSD-41.3 Plt ___ ___ 08:50AM BLOOD Plt ___ ___ 08:50AM BLOOD Glucose-79 UreaN-6 Creat-0.6 Na-139 K-4.1 Cl-104 HCO___* AnGap-18 Brief Hospital Course: Ms. ___ was admitted to the vascular surgery service and started on a heparin drip. Neurovascular exam of the LUE was monitored frequently. On ___ she was taken to the OR for venogram and thrombolysis. Extensive subclavian thrombosis was found, to the level of the 1st rib. Lysis catheter was placed within the thrombus for continued infusion of tPA. The tPA was continuously infused overnight and fibrinogen levels were checked frequently for appropriate dosage. On POD#1 she was taken back to the operating room for planned lysis check. There was residual subclavian vein occlusion. Angioget thrombectomy and balloon angioplasty was performed, but with persistent stenosis at the end of the case. Her LUE was routinely monitored and neurovascular checks were stable. She was started on coumadin for anti-coagulation, due to insurance issues preventing use of NOAC. On POD ___ she was doing well. She was tolerating a diet, denied pain and was mobilizing without difficulty. Her heparin drip was discontinued and she was transitioned to a Lovenox bridge for anticoagulation; she received teaching for injections. Her primary care office was made aware of the plan, and she will follow-up with them early this week for continued anti-coagulation management. She will continue a three-month course of anticoagulation and follow-up in two weeks with Dr. ___ post-operative check and to discuss resection of the left 1st rib. Medications on Admission: N/A Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 60 mg/0.6 mL 1 syringe SC twice per day Disp #*30 Syringe Refills:*0 2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Mild RX *oxycodone 5 mg 1 tablet(s) by mouth every four-six hours Disp #*5 Tablet Refills:*0 3. Warfarin 3 mg PO DAILY16 It is very important that you follow up with your PCP who will change dosing as necessary. RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp #*42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left subclavian vein deep venous thrombosis and likely venous thoracic outlet syndrome. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ___ MD ___ Completed by: ___
[ "I82B12", "G540", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: LUE arm swelling, pain Major Surgical or Invasive Procedure: [MASKED]: thrombolysis of LUE DVT 1. Real-time ultrasound-guided access to the left basilic vein and placement of a [MASKED] sheath. 2. Selective catheterization of the SVC, [MASKED] order vessel. 3. Left upper extremity venogram. 4. Placement of a 20 cm [MASKED] catheter within the left subclavian vein thrombus. [MASKED]: lysis catheter check, removal 1. Lysis check following overnight thrombolysis. 2. Left upper extremity venogram. 3. tPA Angiojet thrombectomy. 4. Balloon angioplasty of the left subclavian vein with a 6 mm balloon. History of Present Illness: [MASKED] woman with no significant past medical history who presented with left upper extremity swelling and was found to have an extensive left subclavian DVT, thought to be secondary to venous thoracic outlet syndrome. Past Medical History: N/A Social History: [MASKED] Family History: N/C Physical Exam: DISCHARGE EXAM: T98.5, HR68, BP91/54, RR 16 96%RA GEN: NAD, AOx3, pleasant CV: RRR PULM: breathing comfortably on room air GI: abdomen soft, NT, ND EXT: LUE swelling decreased, access site clean and dry with minimal ecchymosis, no evidence of hematoma; palpable radial and ulnar pulses; motor/sensory grossly intact Pertinent Results: DISCHARGE LABS: [MASKED] 08:50AM BLOOD WBC-8.3 RBC-4.04 Hgb-12.2 Hct-37.0 MCV-92 MCH-30.2 MCHC-33.0 RDW-12.3 RDWSD-41.3 Plt [MASKED] [MASKED] 08:50AM BLOOD Plt [MASKED] [MASKED] 08:50AM BLOOD Glucose-79 UreaN-6 Creat-0.6 Na-139 K-4.1 Cl-104 HCO * AnGap-18 Brief Hospital Course: Ms. [MASKED] was admitted to the vascular surgery service and started on a heparin drip. Neurovascular exam of the LUE was monitored frequently. On [MASKED] she was taken to the OR for venogram and thrombolysis. Extensive subclavian thrombosis was found, to the level of the 1st rib. Lysis catheter was placed within the thrombus for continued infusion of tPA. The tPA was continuously infused overnight and fibrinogen levels were checked frequently for appropriate dosage. On POD#1 she was taken back to the operating room for planned lysis check. There was residual subclavian vein occlusion. Angioget thrombectomy and balloon angioplasty was performed, but with persistent stenosis at the end of the case. Her LUE was routinely monitored and neurovascular checks were stable. She was started on coumadin for anti-coagulation, due to insurance issues preventing use of NOAC. On POD [MASKED] she was doing well. She was tolerating a diet, denied pain and was mobilizing without difficulty. Her heparin drip was discontinued and she was transitioned to a Lovenox bridge for anticoagulation; she received teaching for injections. Her primary care office was made aware of the plan, and she will follow-up with them early this week for continued anti-coagulation management. She will continue a three-month course of anticoagulation and follow-up in two weeks with Dr. [MASKED] post-operative check and to discuss resection of the left 1st rib. Medications on Admission: N/A Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 60 mg/0.6 mL 1 syringe SC twice per day Disp #*30 Syringe Refills:*0 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q6H:PRN Pain - Mild RX *oxycodone 5 mg 1 tablet(s) by mouth every four-six hours Disp #*5 Tablet Refills:*0 3. Warfarin 3 mg PO DAILY16 It is very important that you follow up with your PCP who will change dosing as necessary. RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp #*42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left subclavian vein deep venous thrombosis and likely venous thoracic outlet syndrome. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "F17210" ]
[ "I82B12: Acute embolism and thrombosis of left subclavian vein", "G540: Brachial plexus disorders", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,058,437
21,570,649
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall with headstrike Major Surgical or Invasive Procedure: None History of Present Illness: Neurosurgery Admission: ___ is a ___ female who presents to ___ on ___ with a mild TBI. Patient has a PMH of AFib on coumadin, CKD, alzheimers, dementia and presents s/p a witnessed fall this afternoon at her nursing facility. Patient was brought to OSH for evaluation. Upon arrival to OSH patient had a NCHCT done that showed an acute on chronic SDH with 0.8cm of midline shift. Patient was found to have an INR of 2.9 and she received KCentra and Vitamin K for reversal. Patient was transferred to ___ for further evaluation and neurosurgery was consulted. Upon examination in ED patient was alert and oriented to self (baseline), year and hospital with choices. She was ___ strength throughout and did not have pronator drift. Patient has dementia at baseline, unable to provide PMH so history obtained through ED report. Mechanism of trauma: Fall Past Medical History: Afib on Coumadin Alzheimer's Dementia CKD Nephrectomy with unilateral kidney Social History: ___ Family History: Unknown Physical Exam: ON ADMISSION: = = = = = = = = = = ================================================================ ___ Physical Exam: T:97.6 HR: 67 BP: 130/88 RR: 16 SPO2: 96% RA GCS at the scene: 14__ GCS upon Neurosurgery Evaluation: 14 Time of evaluation:2220 Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [x]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: WD/WN, comfortable, NAD. Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place (hospital) with choices, and date (___) with choices. Language: Speech is fluent with good comprehension. If Intubated: [ ]Cough [ ]Gag [ ]Over breathing the vent Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Handedness Right DISCHARGE PHYSICAL EXAM: ======================== VS: 24 HR Data (last updated ___ @ 2327) Temp: 97.7 (Tm 98.5), BP: 127/77 (97-136/63-89), HR: 58 (58-91), RR: 18 (___), O2 sat: 96% (94-96), O2 delivery: Ra ___ 0830 T 98.4 BP 130/70 HR 62 RR 18 O2 96% RA HEENT: AT/NC, anicteric sclera and without injection, MMM CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes/rales/rhonchi, breathing comfortably on RA GI: abdomen soft, BS+, nondistended, nontender, no suprapubic tenderness EXTREMITIES: no cyanosis, clubbing, or edema SKIN: Warm and well perfused, no visible rash NEURO: A&Ox1 to self, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS =============== ___ 10:01PM BLOOD WBC-9.6 RBC-3.79* Hgb-11.7 Hct-36.3 MCV-96 MCH-30.9 MCHC-32.2 RDW-13.3 RDWSD-47.0* Plt ___ ___ 10:01PM BLOOD Neuts-79.6* Lymphs-11.5* Monos-7.4 Eos-0.4* Baso-0.7 Im ___ AbsNeut-7.64* AbsLymp-1.10* AbsMono-0.71 AbsEos-0.04 AbsBaso-0.07 ___ 10:01PM BLOOD ___ PTT-24.3* ___ ___ 10:01PM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-139 K-4.5 Cl-104 HCO3-20* AnGap-15 ___ 10:01PM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 DISCHARGE LABS =============== ___ 05:45AM BLOOD WBC-9.5 RBC-3.38* Hgb-10.4* Hct-32.8* MCV-97 MCH-30.8 MCHC-31.7* RDW-14.3 RDWSD-50.4* Plt ___ ___ 05:45AM BLOOD Glucose-74 UreaN-21* Creat-1.2* Na-143 K-4.0 Cl-108 HCO3-22 AnGap-13 ___ 05:45AM BLOOD cTropnT-<0.01 ___ 10:33AM BLOOD cTropnT-<0.01 ___ 05:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS/MICRO ============================ ___ 08:11PM URINE Color-Straw Appear-CLEAR Sp ___ ___ 08:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0 Leuks-SM* ___ 08:11PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE Epi-1 ___ 08:11PM URINE Mucous-RARE* ___ 8:11 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 08:00PM BLOOD Lactate-1.3 ___ 03:31PM URINE Color-Straw Appear-HAZY* Sp ___ ___ 03:31PM URINE Blood-NEG Nitrite-NEG Protein-10* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD* ___ 03:31PM URINE RBC-0 WBC-13* Bacteri-FEW* Yeast-NONE Epi-9 RenalEp-<1 ___ 03:31PM URINE Mucous-FEW* PERTINENT IMAGING ================== CT Head wo Contrast (___) IMPRESSION: - Acute on chronic left subdural hematoma interval slightly increased in size compared to the previous study with slightly worsening 9 mm midline shift to the right and subfalcial herniation. - Small right-sided subdural collection again seen, which contains a small dense component anterior to the frontal lobe also suggesting acute on chronic subdural hematoma. No significant mass effect related to the right subdural collection. EKG (___) Atrial fibrillation with rapid ventricular response, HR ___lock Abnormal ECG When compared with ECG of ___ 21:48, A fib has replaced sinus rhythm QTc 588 EKG (___) - QTc 602 with QRS duration 140ms EKG (___) - QTc 521 EKG (___) - QTc 497 CT Head wo Contrast (___) IMPRESSION: 1. Redemonstration of mixed density subdural hematoma overlying the left frontoparietal convexity measuring 2.3 cm in maximum thickness, not significantly changed in comparison to the prior study. There is associated mass effect with unchanged sulcal effacement and 8 mm of rightward midline shift and subfalcine herniation. 2. Small right-sided subdural hematoma overlying the right frontal convexity, not significantly changed in comparison to the prior study. 3. No evidence of acute large territory infarction or new hemorrhage. Brief Hospital Course: SUMMARY ============ ___ is a ___ year old female who presented to OSH s/p an unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. Patient was then transferred to medicine where she remained stable, and was recommended to go to rehab by physical therapy. TRANSITIONAL ISSUES ==================== [] Pt will continue to hold any anticoagulation until follow up with Dr. ___ in 1 week with a repeat Head CT [] Follow-up chemistry on ___ to monitor electrolytes and kidney function [] Held several medications due to prolonged QTc - recommend rechecking EKG as outpatient and consider restarting appropriate meds [] Sertraline held due to prolonged QTc, consider alternative antidepressant [] Amiodarone held this admission due to prolonged QTc, although was still having RVR earlier in admission on Amio - consider adjusting regimen for atrial fibrillation [] ensure enlive 4x/day, encourage PO intake [] manage constipation ACUTE ISSUES ============== #Acute on Chronic SDH Unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Patient was taking Coumadin for history of Afib and INR at OSH was 2.9, Kcentra and vitamin K was given and INR on arrival to our ED was 1.2. Patient was admitted to the neurosurgery service and transferred to the ___ from the ED. Coumadin was held on admission. Patient remained what appeared to be at her neurological baseline. CTH in the AM on ___ revealed a slightly larger left SDH and a very small right frontal SDH. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. On ___, the patient's neurologic checks were liberalized and she was transferred to the floor. Given vomiting, had repeat CT Head ___ which was stable from prior. #Atrial Fibrillation, on coumadin CHADS-VASc = 3 for age and female gender. On warfarin, amiodarone, and metoprolol at home. This admission, patient was continued on metoprolol and had episodes of RVR as well as episodes of bradycardia. Metoprolol was adjusted to prior home dose and HRs remained stable. Amiodarone was held in the setting of prolonged QTc. Warfarin was held in setting of acute on chronic SDH, with plans to continue holding until 2 week follow-up NCHCT with neurosurgery. #Prolonged QTc Noted on initial ECGs. Likely secondary to multiple medications that can prolong the QTc. Several medications were stopped and repeat EKG with QTc<500. Later in hospital course, QTc was rechecked and was in 500s. Continued to hold home medications that can contribute to prolonged QTc at time of discharge. ___ Pt with Cr 1.3 during admission in setting of poor PO intake, improved with IVF. Also with orthostasis with SBP 100s lying down to ___ standing, as well as decreased UOP. s/p another 1L LR and no longer orthostatic with improved urine output. Cr on discharge was 1.2. #Asymptomatic Pyuria UA with 13 WBC and moderate leuks however patient was asymptomatic and without dysuria or suprapubic tenderness on exam. Had leukocytosis to 12 later in admission which resolved after IVF, possibly representing hemoconcentration. Overall not concerning for active infection. #Fall Unwitnessed fall at nursing home. Unclear what work up was performed at OSH. Here she has had episodes of RVR on telemetry. No murmurs on exam to suggest valvular pathology. NO infectious signs/symptoms. Orthostasis is possible, however BPs have been stable this admission. Likely etiology was mechanical fall as etiology. Evaluated by ___ and recommended to go to ___ rehab. #Heartburn #GERD On day of discharge, patient reported epigastric and left-sided chest pain as well as nausea and lightheadedness. Received tums and symptoms completely resolved. Also received aspirin x1 however low suspicion for cardiac etiology. EKG obtained and was stable from prior, no ST or T wave changes. Vitals were stable during the event. Trops <0.01 x2. Likely represented heartburn/reflux given rapid improvement with tums. Was given Maalox/Diphenhydramine/Lidocaine for symptoms. Had also been receiving home PPI daily during admission. #Vomiting #Constipation Pt with vomiting x2 later in admission, not taking much PO as a result. CT Head ___ stable from prior. Pt asymptomatic and denied abd pain, n/v at those times, no localizing symptoms. Suspect constipation a large driver. Increased bowel regimen. Pt did not have further episodes of vomiting and remained asymptomatic. #T2 and T4 compression fractures (diagnosed at OSH) Per family she suffered a fall about 4 weeks ago and was dx with a T2 and T4 compression fracture at that time. She was discharged from the ED without intervention and recommendation to follow up with her PCP who ordered ___ TLSO brace. She has no back pain or midline spinal tenderness and has been ambulating without any brace for 4 week now. Neurosurgery felt that she did not require a brace or any further intervention. It was felt that she may continue activity as tolerated. # Anion gap metabolic acidosis Progressively downtrended bicarb in the absence of clear etiology. No uremia, lactate wnl, UA without evidence of ketones. No significant diarrhea. Improving at the time of discharge. #Nutrition Concerns about poor PO intake from nursing staff and son. ___ by nutrition who recommended 4 Ensure Enlives per day. Pt was given thiamine 100mg daily as well as phosphorus repletion. CHRONIC ISSUES: =============== #CKD Cr remained wnl and stable this admission. #HLD Continued on home simvastatin 10mg qPM #Hypothyroidism Continued on home levothyroxine 50mcg daily #Alzheimers Continued on home memantine 5mg PO BID, ramelteon 8mg qPM prn. #Depression Held home sertraline in setting of prolonged QTc Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 2. Amiodarone 200 mg PO EVERY OTHER DAY 3. Ferrous Sulfate 325 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Memantine 5 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Pantoprazole 20 mg PO EVERY OTHER DAY 8. Sertraline 25 mg PO DAILY 9. Simvastatin 10 mg PO QPM 10. Warfarin 3 mg PO DAILY 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. Gabapentin 200 mg PO QAM 13. Gabapentin 300 mg PO QHS 14. melatonin 3 mg oral QHS Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn 2. Polyethylene Glycol 17 g PO DAILY 3. Pantoprazole 20 mg PO Q24H 4. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 5. Ferrous Sulfate 325 mg PO BID 6. Gabapentin 200 mg PO QAM 7. Gabapentin 300 mg PO QHS 8. Levothyroxine Sodium 50 mcg PO DAILY 9. melatonin 3 mg oral QHS 10. Memantine 5 mg PO BID 11. Metoprolol Tartrate 12.5 mg PO BID 12. Simvastatin 10 mg PO QPM 13. HELD- Amiodarone 200 mg PO EVERY OTHER DAY This medication was held. Do not restart Amiodarone until you see your primary care doctor. 14. HELD- Sertraline 25 mg PO DAILY This medication was held. Do not restart Sertraline until you see your primary care doctor. 15. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This medication was held. Do not restart TraMADol until you see your doctor 16. HELD- Warfarin 3 mg PO DAILY This medication was held. Do not restart Warfarin until you see Dr. ___ in a few weeks. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Left acute on chronic SDH Small right acute SDH SECONDARY DIAGNOSIS: Prolonged QTc Atrial Fibrillation Anion gap metabolic acidosis 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 came into the hospital after a fall and were found to have new bleeding in your brain, as well as findings of old bleeding. You were monitored closely and you did not require surgical intervention. Some of your home medications were also adjusted. Please see the medication changes listed below for the complete list. It was a pleasure taking care of you! - Your ___ Medicine Team 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. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason Followup Instructions: ___
[ "S065X0A", "S22020A", "S22040A", "N179", "E872", "D6832", "I4820", "Z7901", "N189", "G309", "F0280", "R402143", "R402243", "R402363", "I4581", "K219", "R1110", "K5900", "E785", "Y92129", "W19XXXA", "E039", "I447", "T45525A", "F329", "R8281", "D72829" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fall with headstrike Major Surgical or Invasive Procedure: None History of Present Illness: Neurosurgery Admission: [MASKED] is a [MASKED] female who presents to [MASKED] on [MASKED] with a mild TBI. Patient has a PMH of AFib on coumadin, CKD, alzheimers, dementia and presents s/p a witnessed fall this afternoon at her nursing facility. Patient was brought to OSH for evaluation. Upon arrival to OSH patient had a NCHCT done that showed an acute on chronic SDH with 0.8cm of midline shift. Patient was found to have an INR of 2.9 and she received KCentra and Vitamin K for reversal. Patient was transferred to [MASKED] for further evaluation and neurosurgery was consulted. Upon examination in ED patient was alert and oriented to self (baseline), year and hospital with choices. She was [MASKED] strength throughout and did not have pronator drift. Patient has dementia at baseline, unable to provide PMH so history obtained through ED report. Mechanism of trauma: Fall Past Medical History: Afib on Coumadin Alzheimer's Dementia CKD Nephrectomy with unilateral kidney Social History: [MASKED] Family History: Unknown Physical Exam: ON ADMISSION: = = = = = = = = = = ================================================================ [MASKED] Physical Exam: T:97.6 HR: 67 BP: 130/88 RR: 16 SPO2: 96% RA GCS at the scene: 14 GCS upon Neurosurgery Evaluation: 14 Time of evaluation:2220 Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [x]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ [MASKED] Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: WD/WN, comfortable, NAD. Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place (hospital) with choices, and date ([MASKED]) with choices. Language: Speech is fluent with good comprehension. If Intubated: [ ]Cough [ ]Gag [ ]Over breathing the vent Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. No pronator drift Sensation: Intact to light touch Handedness Right DISCHARGE PHYSICAL EXAM: ======================== VS: 24 HR Data (last updated [MASKED] @ 2327) Temp: 97.7 (Tm 98.5), BP: 127/77 (97-136/63-89), HR: 58 (58-91), RR: 18 ([MASKED]), O2 sat: 96% (94-96), O2 delivery: Ra [MASKED] 0830 T 98.4 BP 130/70 HR 62 RR 18 O2 96% RA HEENT: AT/NC, anicteric sclera and without injection, MMM CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes/rales/rhonchi, breathing comfortably on RA GI: abdomen soft, BS+, nondistended, nontender, no suprapubic tenderness EXTREMITIES: no cyanosis, clubbing, or edema SKIN: Warm and well perfused, no visible rash NEURO: A&Ox1 to self, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS =============== [MASKED] 10:01PM BLOOD WBC-9.6 RBC-3.79* Hgb-11.7 Hct-36.3 MCV-96 MCH-30.9 MCHC-32.2 RDW-13.3 RDWSD-47.0* Plt [MASKED] [MASKED] 10:01PM BLOOD Neuts-79.6* Lymphs-11.5* Monos-7.4 Eos-0.4* Baso-0.7 Im [MASKED] AbsNeut-7.64* AbsLymp-1.10* AbsMono-0.71 AbsEos-0.04 AbsBaso-0.07 [MASKED] 10:01PM BLOOD [MASKED] PTT-24.3* [MASKED] [MASKED] 10:01PM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-139 K-4.5 Cl-104 HCO3-20* AnGap-15 [MASKED] 10:01PM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 DISCHARGE LABS =============== [MASKED] 05:45AM BLOOD WBC-9.5 RBC-3.38* Hgb-10.4* Hct-32.8* MCV-97 MCH-30.8 MCHC-31.7* RDW-14.3 RDWSD-50.4* Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-74 UreaN-21* Creat-1.2* Na-143 K-4.0 Cl-108 HCO3-22 AnGap-13 [MASKED] 05:45AM BLOOD cTropnT-<0.01 [MASKED] 10:33AM BLOOD cTropnT-<0.01 [MASKED] 05:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS/MICRO ============================ [MASKED] 08:11PM URINE Color-Straw Appear-CLEAR Sp [MASKED] [MASKED] 08:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0 Leuks-SM* [MASKED] 08:11PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE Epi-1 [MASKED] 08:11PM URINE Mucous-RARE* [MASKED] 8:11 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 08:00PM BLOOD Lactate-1.3 [MASKED] 03:31PM URINE Color-Straw Appear-HAZY* Sp [MASKED] [MASKED] 03:31PM URINE Blood-NEG Nitrite-NEG Protein-10* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD* [MASKED] 03:31PM URINE RBC-0 WBC-13* Bacteri-FEW* Yeast-NONE Epi-9 RenalEp-<1 [MASKED] 03:31PM URINE Mucous-FEW* PERTINENT IMAGING ================== CT Head wo Contrast ([MASKED]) IMPRESSION: - Acute on chronic left subdural hematoma interval slightly increased in size compared to the previous study with slightly worsening 9 mm midline shift to the right and subfalcial herniation. - Small right-sided subdural collection again seen, which contains a small dense component anterior to the frontal lobe also suggesting acute on chronic subdural hematoma. No significant mass effect related to the right subdural collection. EKG ([MASKED]) Atrial fibrillation with rapid ventricular response, HR lock Abnormal ECG When compared with ECG of [MASKED] 21:48, A fib has replaced sinus rhythm QTc 588 EKG ([MASKED]) - QTc 602 with QRS duration 140ms EKG ([MASKED]) - QTc 521 EKG ([MASKED]) - QTc 497 CT Head wo Contrast ([MASKED]) IMPRESSION: 1. Redemonstration of mixed density subdural hematoma overlying the left frontoparietal convexity measuring 2.3 cm in maximum thickness, not significantly changed in comparison to the prior study. There is associated mass effect with unchanged sulcal effacement and 8 mm of rightward midline shift and subfalcine herniation. 2. Small right-sided subdural hematoma overlying the right frontal convexity, not significantly changed in comparison to the prior study. 3. No evidence of acute large territory infarction or new hemorrhage. Brief Hospital Course: SUMMARY ============ [MASKED] is a [MASKED] year old female who presented to OSH s/p an unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. Patient was then transferred to medicine where she remained stable, and was recommended to go to rehab by physical therapy. TRANSITIONAL ISSUES ==================== [] Pt will continue to hold any anticoagulation until follow up with Dr. [MASKED] in 1 week with a repeat Head CT [] Follow-up chemistry on [MASKED] to monitor electrolytes and kidney function [] Held several medications due to prolonged QTc - recommend rechecking EKG as outpatient and consider restarting appropriate meds [] Sertraline held due to prolonged QTc, consider alternative antidepressant [] Amiodarone held this admission due to prolonged QTc, although was still having RVR earlier in admission on Amio - consider adjusting regimen for atrial fibrillation [] ensure enlive 4x/day, encourage PO intake [] manage constipation ACUTE ISSUES ============== #Acute on Chronic SDH Unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Patient was taking Coumadin for history of Afib and INR at OSH was 2.9, Kcentra and vitamin K was given and INR on arrival to our ED was 1.2. Patient was admitted to the neurosurgery service and transferred to the [MASKED] from the ED. Coumadin was held on admission. Patient remained what appeared to be at her neurological baseline. CTH in the AM on [MASKED] revealed a slightly larger left SDH and a very small right frontal SDH. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. On [MASKED], the patient's neurologic checks were liberalized and she was transferred to the floor. Given vomiting, had repeat CT Head [MASKED] which was stable from prior. #Atrial Fibrillation, on coumadin CHADS-VASc = 3 for age and female gender. On warfarin, amiodarone, and metoprolol at home. This admission, patient was continued on metoprolol and had episodes of RVR as well as episodes of bradycardia. Metoprolol was adjusted to prior home dose and HRs remained stable. Amiodarone was held in the setting of prolonged QTc. Warfarin was held in setting of acute on chronic SDH, with plans to continue holding until 2 week follow-up NCHCT with neurosurgery. #Prolonged QTc Noted on initial ECGs. Likely secondary to multiple medications that can prolong the QTc. Several medications were stopped and repeat EKG with QTc<500. Later in hospital course, QTc was rechecked and was in 500s. Continued to hold home medications that can contribute to prolonged QTc at time of discharge. [MASKED] Pt with Cr 1.3 during admission in setting of poor PO intake, improved with IVF. Also with orthostasis with SBP 100s lying down to [MASKED] standing, as well as decreased UOP. s/p another 1L LR and no longer orthostatic with improved urine output. Cr on discharge was 1.2. #Asymptomatic Pyuria UA with 13 WBC and moderate leuks however patient was asymptomatic and without dysuria or suprapubic tenderness on exam. Had leukocytosis to 12 later in admission which resolved after IVF, possibly representing hemoconcentration. Overall not concerning for active infection. #Fall Unwitnessed fall at nursing home. Unclear what work up was performed at OSH. Here she has had episodes of RVR on telemetry. No murmurs on exam to suggest valvular pathology. NO infectious signs/symptoms. Orthostasis is possible, however BPs have been stable this admission. Likely etiology was mechanical fall as etiology. Evaluated by [MASKED] and recommended to go to [MASKED] rehab. #Heartburn #GERD On day of discharge, patient reported epigastric and left-sided chest pain as well as nausea and lightheadedness. Received tums and symptoms completely resolved. Also received aspirin x1 however low suspicion for cardiac etiology. EKG obtained and was stable from prior, no ST or T wave changes. Vitals were stable during the event. Trops <0.01 x2. Likely represented heartburn/reflux given rapid improvement with tums. Was given Maalox/Diphenhydramine/Lidocaine for symptoms. Had also been receiving home PPI daily during admission. #Vomiting #Constipation Pt with vomiting x2 later in admission, not taking much PO as a result. CT Head [MASKED] stable from prior. Pt asymptomatic and denied abd pain, n/v at those times, no localizing symptoms. Suspect constipation a large driver. Increased bowel regimen. Pt did not have further episodes of vomiting and remained asymptomatic. #T2 and T4 compression fractures (diagnosed at OSH) Per family she suffered a fall about 4 weeks ago and was dx with a T2 and T4 compression fracture at that time. She was discharged from the ED without intervention and recommendation to follow up with her PCP who ordered [MASKED] TLSO brace. She has no back pain or midline spinal tenderness and has been ambulating without any brace for 4 week now. Neurosurgery felt that she did not require a brace or any further intervention. It was felt that she may continue activity as tolerated. # Anion gap metabolic acidosis Progressively downtrended bicarb in the absence of clear etiology. No uremia, lactate wnl, UA without evidence of ketones. No significant diarrhea. Improving at the time of discharge. #Nutrition Concerns about poor PO intake from nursing staff and son. [MASKED] by nutrition who recommended 4 Ensure Enlives per day. Pt was given thiamine 100mg daily as well as phosphorus repletion. CHRONIC ISSUES: =============== #CKD Cr remained wnl and stable this admission. #HLD Continued on home simvastatin 10mg qPM #Hypothyroidism Continued on home levothyroxine 50mcg daily #Alzheimers Continued on home memantine 5mg PO BID, ramelteon 8mg qPM prn. #Depression Held home sertraline in setting of prolonged QTc Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 2. Amiodarone 200 mg PO EVERY OTHER DAY 3. Ferrous Sulfate 325 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Memantine 5 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Pantoprazole 20 mg PO EVERY OTHER DAY 8. Sertraline 25 mg PO DAILY 9. Simvastatin 10 mg PO QPM 10. Warfarin 3 mg PO DAILY 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. Gabapentin 200 mg PO QAM 13. Gabapentin 300 mg PO QHS 14. melatonin 3 mg oral QHS Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn 2. Polyethylene Glycol 17 g PO DAILY 3. Pantoprazole 20 mg PO Q24H 4. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 5. Ferrous Sulfate 325 mg PO BID 6. Gabapentin 200 mg PO QAM 7. Gabapentin 300 mg PO QHS 8. Levothyroxine Sodium 50 mcg PO DAILY 9. melatonin 3 mg oral QHS 10. Memantine 5 mg PO BID 11. Metoprolol Tartrate 12.5 mg PO BID 12. Simvastatin 10 mg PO QPM 13. HELD- Amiodarone 200 mg PO EVERY OTHER DAY This medication was held. Do not restart Amiodarone until you see your primary care doctor. 14. HELD- Sertraline 25 mg PO DAILY This medication was held. Do not restart Sertraline until you see your primary care doctor. 15. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This medication was held. Do not restart TraMADol until you see your doctor 16. HELD- Warfarin 3 mg PO DAILY This medication was held. Do not restart Warfarin until you see Dr. [MASKED] in a few weeks. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Left acute on chronic SDH Small right acute SDH SECONDARY DIAGNOSIS: Prolonged QTc Atrial Fibrillation Anion gap metabolic acidosis 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 came into the hospital after a fall and were found to have new bleeding in your brain, as well as findings of old bleeding. You were monitored closely and you did not require surgical intervention. Some of your home medications were also adjusted. Please see the medication changes listed below for the complete list. It was a pleasure taking care of you! - Your [MASKED] Medicine Team 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. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason Followup Instructions: [MASKED]
[]
[ "N179", "E872", "Z7901", "N189", "K219", "K5900", "E785", "E039", "F329" ]
[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "S22020A: Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture", "S22040A: Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "I4820: Chronic atrial fibrillation, unspecified", "Z7901: Long term (current) use of anticoagulants", "N189: Chronic kidney disease, unspecified", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "R402143: Coma scale, eyes open, spontaneous, at hospital admission", "R402243: Coma scale, best verbal response, confused conversation, at hospital admission", "R402363: Coma scale, best motor response, obeys commands, at hospital admission", "I4581: Long QT syndrome", "K219: Gastro-esophageal reflux disease without esophagitis", "R1110: Vomiting, unspecified", "K5900: Constipation, unspecified", "E785: Hyperlipidemia, unspecified", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause", "W19XXXA: Unspecified fall, initial encounter", "E039: Hypothyroidism, unspecified", "I447: Left bundle-branch block, unspecified", "T45525A: Adverse effect of antithrombotic drugs, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "R8281: Pyuria", "D72829: Elevated white blood cell count, unspecified" ]
10,058,575
22,995,646
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever, tachycardia Major Surgical or Invasive Procedure: Injury burden from prior admission s/p MVC: Right subdural hematoma Right traumatic subarachnoid hemorrhage C1 fracture Complete transection of the right internal carotid artery Right orbit lateral wall fracture Acute fracture of the left posterior maxillary sinus Temporal bone fracture Right side rib fractures (___) Right femur fracture Right tibial plateau fracture Left ankle fracture Right external iliac vein thrombosis Secondary: Malnutrition secondary to ___ ___ pneumonia Central line associated blood stream infection Urinary Tract Infection Recent admission: ___: no surgical interventions History of Present Illness: ___ year old female, s/p MVC ___ resulting in multiple ___ fractures (s/p ORIF___), right internal carotid injury (managed non-op), b/l facial fractures (non-op), s/p trach ___, s/p PEG ___, conversion to GJ ___ (on home TFs), SDH, SAH & IPH, who was discharged from ___ to rehab on ___ after a prolonged hospital course, now presenting from rehab febrile to 104 per report, and tachycardic to 140s in the ___ ED. Past Medical History: PMH: DM, hypothyroidism, "unclear liver disease" per family PSH: Unknown Social History: ___ Family History: non-contributory Physical Exam: Physical Exam: upon admission: ___: Vitals: Tcurrent 100.6, HR 90, BP 119/78, RR 18, O2 Sat 100% on TM mist General: NAD, nontoxic appearing, resting comfortably on hospital stretcher in ED HEENT: normocephalic, atraumatic; EOMI; MMM; trach in place with no signs of surrounding skin breakdown, no signs of oral thrush Resp: nonlabored breathing on TM mist; coarse cough bilaterally, nonproductive; diminished breath sounds on right side compared to left CV: RRR, palpable peripheral pulses Abd: soft, nontender, nondistended; no rebound or guarding GU: foley in place draining clear yellow urine Neuro: CN ___ grossly intact, moves all extremities spontaneously Discharge Physical Exam: ___ 97.8, 90, 119/80, 18, 100%TM Gen: A&O, resting comfortably in NARD, ___ J collar in place CV: ns1, s2, no murmurs LUNGS: coarse BS bil. ABDOMEN: soft, non-tender, G tube site clean and dry EXT: + dp bil., no calf tenderness bil., no pedal edema bil, knee immoblizer left knee NEURO: opens eyes, follows simple commands Pertinent Results: ___ 07:40AM BLOOD WBC-8.8 RBC-2.57* Hgb-7.1* Hct-23.4* MCV-91 MCH-27.6 MCHC-30.3* RDW-15.0 RDWSD-49.2* Plt ___ ___ 07:20AM BLOOD WBC-8.2 RBC-2.63* Hgb-7.1* Hct-24.2* MCV-92 MCH-27.0 MCHC-29.3* RDW-15.1 RDWSD-50.6* Plt ___ ___ 07:00AM BLOOD WBC-9.3 RBC-2.81* Hgb-7.6* Hct-25.9* MCV-92 MCH-27.0 MCHC-29.3* RDW-15.0 RDWSD-50.8* Plt ___ ___ 05:30AM BLOOD WBC-15.0*# RBC-2.95* Hgb-8.1* Hct-27.3* MCV-93 MCH-27.5 MCHC-29.7* RDW-15.9* RDWSD-53.6* Plt ___ ___ 05:30AM BLOOD Neuts-77.1* Lymphs-18.7* Monos-3.2* Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.57* AbsLymp-2.81 AbsMono-0.48 AbsEos-0.01* AbsBaso-0.04 ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD ___ PTT-30.3 ___ ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ ___ 07:40AM BLOOD Glucose-153* UreaN-7 Creat-0.5 Na-139 K-3.7 Cl-99 HCO3-27 AnGap-17 ___ 07:20AM BLOOD Glucose-162* UreaN-8 Creat-0.5 Na-137 K-3.7 Cl-97 HCO3-27 AnGap-17 ___ 07:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8 ___ 07:20AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 ___: CXR: Worsened airspace opacification in the right lung is concerning for pneumonia, possibly due to chronic aspiration. Because of recurrent pneumonias, the presence of a tracheo-esophageal fistula should be considered. ___: CT abd/pelvis: Multifocal pneumonia involving the dependent portions of the right upper and lower lobes, as well as a small portion of the left lower lobe. Given the distribution and existing tracheostomy tube, aspiration pneumonia is a likely etiology. 2. No identifiable pathology in the abdomen or pelvis. 3. Mal-positioned left PICC line terminating in the azygos vein. ___: CXR: The tip of the left PICC line now projects over the upper SVC. Airspace opacities throughout the right lung and left base have slightly decreased. ___: CXR: Mild interval decrease in right base consolidation, consistent with resolving pneumonia. ___: CT c-spine: 1. Grossly unchanged appearance of the left C1 posterior arch fracture with no significant interval osseous callus formation since ___. 2. Stable multiple sub-cute fractures of the skull-base 3. No new fractures. 4. Unchanged mild multilevel degenerative changes of the cervical spine. ___ 5:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___. ___ @ 10:09AM ___ 5:30 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 CFU/mL ___ 3:52 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ___ 1:56 pm STOOL CONSISTENCY: FORMED Source: Rectal swab. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative Brief Hospital Course: ___ yo female s/p MVC ___ presenting with multiple lower extremity fractures,(s/p ORIF ___, right internal carotid injury(managed non-op), bilateral facial fractures (non-op), s/p trach ___, s/p PEG ___, conversion to GJ ___ (on home TFs), SDH, SAH & IPH, who was discharged from ___ to rehab on ___ after a prolonged hospital course. She re-presented to the hospital from rehab on ___ with a fever to 104 and tachycardia to 140. She reportedly had a white blood cell count of 15. Upon admission, the patient was made NPO, given intravenous fluids and underwent imaging. A cat scan of the torso showed multi-focal pneumonia. The patient was started on intravenous Vancomycin and Zosyn. Blood, sputum and urine cultures were obtained. On review of imaging, the PICC line was reported to be mal-positioned. It was repositioned and chest-ray imaging showed it projecting over the upper SVC. During the patient's hospitalization, imaging studies of the head and neck were repeated and remained unchanged. She remained in her ___ collar until follow-up with Neurosurgery. The patient resumed tube feedings via the GJ tube. She was re-evaluated by Speech and Swallow service to determine if the patient could resume oral supplements. The assessment could not be completed related to the patient's inability to follow instruction. The foley catheter was removed and the patient was incontinent of urine. The patient resumed anti-coagulation medications with monitoring of ___ attaining a goal of 2.0-3.0. Initial blood cultures grew staphylococcus, coagulase negative, but subsequent blood cultures reportedly showed no growth. Her sputum culture reportedly grew e.coli and klebseilla and the patient transitioned to a course of augmentin, last dose ___. Her repeat sputum culture on ___ showed no micro-organisms. On ___, the patient was reported to have diarrhea which was negative for c.diff. Tube feeding changes were undertaken per recommendations of Nutrition to help decrease the diarrhea. In preparation for discharge, the patient was evaluated by physical and occupational therapy and recommendations were made for discharge to a rehabilitation facility. The patient was discharged on HD #9 with stable vital signs. Her white blood cell count had normalized and her hematocrit remained stable at 23.4. She was tolerating her tube feedings via the GJ tube. Her INR at the time of discharge was 1.4. Appointments for follow-up were made with the Orthopedic, Neurosurgery, and Acute care surgery clinics. Medications on Admission: MEDICATIONS: Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild Acetylcysteine 20% ___ mL NEB Q4H:PRN mucus plugging Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Aspirin 81 mg PO DAILY Bisacodyl 10 mg PR QHS:PRN constipation Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID Glargine 12 Units Breakfast Glargine 14 Units Bedtime Insulin SC Sliding Scale using REG Insulin Ipratropium-Albuterol Neb 1 NEB NEB Q6H Levothyroxine Sodium 150 mcg PO DAILY Metoclopramide 10 mg PO QIDACHS Metoprolol Tartrate 12.5 mg PO BID Milk of Magnesia 30 mL PO Q6H:PRN constipation Nystatin Oral Suspension 5 mL PO QID:PRN thrush OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate Pantoprazole 40 mg PO Q24H TiCAGRELOR 90 mg PO BID Duration: ___ ___ MD to order daily dose PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN mucous plugging 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H last dose ___ 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 5. Aspirin 81 mg PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Lantus (insulin glargine) 14 units subcutaneous BEDTIME 10. LORazepam 1 mg PO Q6H:PRN agitation 11. Metoclopramide 10 mg PO QIDACHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. OxycoDONE Liquid 5 mg PO Q8H:PRN Pain - Moderate hold for increased sedation, resp. rate <8 14. Pantoprazole 40 mg IV Q24H 15. Warfarin 4 mg PO ONCE Duration: 1 Dose 16. insulin glargine 12 subcutaneous Breakfast 17. Levothyroxine Sodium 150 mcg PO DAILY 18. Metoprolol Tartrate 12.5 mg PO BID 19. TiCAGRELOR 90 mg PO BID 20. ___ MD to order daily dose PO DAILY16 daily dose based on daily ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were re-admitted to the hospital from the rehabilitation center with fever, and tachycardia. You were also noted to have an elevated white blood cell count. You underwent a cat scan and you were found to have pneumonia. You were started on antibiotics. Your white blood cell count has normalized and you are preparing to return to the rehabilitation center to regain your strength and mobility. You are being discharged with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids Followup Instructions: ___
[ "J690", "T82524A", "E46", "Z930", "Z931", "B3749", "E039", "Y828", "Y929", "R32", "Z794", "S12000D", "S0240DD", "S062X0D", "V892XXD", "Z6830", "S0219XD", "S0281XD", "S2241XD", "S7291XE", "S82141D", "E119" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fever, tachycardia Major Surgical or Invasive Procedure: Injury burden from prior admission s/p MVC: Right subdural hematoma Right traumatic subarachnoid hemorrhage C1 fracture Complete transection of the right internal carotid artery Right orbit lateral wall fracture Acute fracture of the left posterior maxillary sinus Temporal bone fracture Right side rib fractures ([MASKED]) Right femur fracture Right tibial plateau fracture Left ankle fracture Right external iliac vein thrombosis Secondary: Malnutrition secondary to [MASKED] [MASKED] pneumonia Central line associated blood stream infection Urinary Tract Infection Recent admission: [MASKED]: no surgical interventions History of Present Illness: [MASKED] year old female, s/p MVC [MASKED] resulting in multiple [MASKED] fractures (s/p ORIF ), right internal carotid injury (managed non-op), b/l facial fractures (non-op), s/p trach [MASKED], s/p PEG [MASKED], conversion to GJ [MASKED] (on home TFs), SDH, SAH & IPH, who was discharged from [MASKED] to rehab on [MASKED] after a prolonged hospital course, now presenting from rehab febrile to 104 per report, and tachycardic to 140s in the [MASKED] ED. Past Medical History: PMH: DM, hypothyroidism, "unclear liver disease" per family PSH: Unknown Social History: [MASKED] Family History: non-contributory Physical Exam: Physical Exam: upon admission: [MASKED]: Vitals: Tcurrent 100.6, HR 90, BP 119/78, RR 18, O2 Sat 100% on TM mist General: NAD, nontoxic appearing, resting comfortably on hospital stretcher in ED HEENT: normocephalic, atraumatic; EOMI; MMM; trach in place with no signs of surrounding skin breakdown, no signs of oral thrush Resp: nonlabored breathing on TM mist; coarse cough bilaterally, nonproductive; diminished breath sounds on right side compared to left CV: RRR, palpable peripheral pulses Abd: soft, nontender, nondistended; no rebound or guarding GU: foley in place draining clear yellow urine Neuro: CN [MASKED] grossly intact, moves all extremities spontaneously Discharge Physical Exam: [MASKED] 97.8, 90, 119/80, 18, 100%TM Gen: A&O, resting comfortably in NARD, [MASKED] J collar in place CV: ns1, s2, no murmurs LUNGS: coarse BS bil. ABDOMEN: soft, non-tender, G tube site clean and dry EXT: + dp bil., no calf tenderness bil., no pedal edema bil, knee immoblizer left knee NEURO: opens eyes, follows simple commands Pertinent Results: [MASKED] 07:40AM BLOOD WBC-8.8 RBC-2.57* Hgb-7.1* Hct-23.4* MCV-91 MCH-27.6 MCHC-30.3* RDW-15.0 RDWSD-49.2* Plt [MASKED] [MASKED] 07:20AM BLOOD WBC-8.2 RBC-2.63* Hgb-7.1* Hct-24.2* MCV-92 MCH-27.0 MCHC-29.3* RDW-15.1 RDWSD-50.6* Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-9.3 RBC-2.81* Hgb-7.6* Hct-25.9* MCV-92 MCH-27.0 MCHC-29.3* RDW-15.0 RDWSD-50.8* Plt [MASKED] [MASKED] 05:30AM BLOOD WBC-15.0*# RBC-2.95* Hgb-8.1* Hct-27.3* MCV-93 MCH-27.5 MCHC-29.7* RDW-15.9* RDWSD-53.6* Plt [MASKED] [MASKED] 05:30AM BLOOD Neuts-77.1* Lymphs-18.7* Monos-3.2* Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-11.57* AbsLymp-2.81 AbsMono-0.48 AbsEos-0.01* AbsBaso-0.04 [MASKED] 07:40AM BLOOD Plt [MASKED] [MASKED] 07:40AM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 07:20AM BLOOD Plt [MASKED] [MASKED] 07:20AM BLOOD [MASKED] [MASKED] 07:00AM BLOOD Plt [MASKED] [MASKED] 07:00AM BLOOD [MASKED] [MASKED] 07:40AM BLOOD Glucose-153* UreaN-7 Creat-0.5 Na-139 K-3.7 Cl-99 HCO3-27 AnGap-17 [MASKED] 07:20AM BLOOD Glucose-162* UreaN-8 Creat-0.5 Na-137 K-3.7 Cl-97 HCO3-27 AnGap-17 [MASKED] 07:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8 [MASKED] 07:20AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 [MASKED]: CXR: Worsened airspace opacification in the right lung is concerning for pneumonia, possibly due to chronic aspiration. Because of recurrent pneumonias, the presence of a tracheo-esophageal fistula should be considered. [MASKED]: CT abd/pelvis: Multifocal pneumonia involving the dependent portions of the right upper and lower lobes, as well as a small portion of the left lower lobe. Given the distribution and existing tracheostomy tube, aspiration pneumonia is a likely etiology. 2. No identifiable pathology in the abdomen or pelvis. 3. Mal-positioned left PICC line terminating in the azygos vein. [MASKED]: CXR: The tip of the left PICC line now projects over the upper SVC. Airspace opacities throughout the right lung and left base have slightly decreased. [MASKED]: CXR: Mild interval decrease in right base consolidation, consistent with resolving pneumonia. [MASKED]: CT c-spine: 1. Grossly unchanged appearance of the left C1 posterior arch fracture with no significant interval osseous callus formation since [MASKED]. 2. Stable multiple sub-cute fractures of the skull-base 3. No new fractures. 4. Unchanged mild multilevel degenerative changes of the cervical spine. [MASKED] 5:30 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [MASKED]. [MASKED] @ 10:09AM [MASKED] 5:30 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: YEAST. 10,000-100,000 CFU/mL [MASKED] 3:52 am SPUTUM Source: Endotracheal. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [MASKED] 1:56 pm STOOL CONSISTENCY: FORMED Source: Rectal swab. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative Brief Hospital Course: [MASKED] yo female s/p MVC [MASKED] presenting with multiple lower extremity fractures,(s/p ORIF [MASKED], right internal carotid injury(managed non-op), bilateral facial fractures (non-op), s/p trach [MASKED], s/p PEG [MASKED], conversion to GJ [MASKED] (on home TFs), SDH, SAH & IPH, who was discharged from [MASKED] to rehab on [MASKED] after a prolonged hospital course. She re-presented to the hospital from rehab on [MASKED] with a fever to 104 and tachycardia to 140. She reportedly had a white blood cell count of 15. Upon admission, the patient was made NPO, given intravenous fluids and underwent imaging. A cat scan of the torso showed multi-focal pneumonia. The patient was started on intravenous Vancomycin and Zosyn. Blood, sputum and urine cultures were obtained. On review of imaging, the PICC line was reported to be mal-positioned. It was repositioned and chest-ray imaging showed it projecting over the upper SVC. During the patient's hospitalization, imaging studies of the head and neck were repeated and remained unchanged. She remained in her [MASKED] collar until follow-up with Neurosurgery. The patient resumed tube feedings via the GJ tube. She was re-evaluated by Speech and Swallow service to determine if the patient could resume oral supplements. The assessment could not be completed related to the patient's inability to follow instruction. The foley catheter was removed and the patient was incontinent of urine. The patient resumed anti-coagulation medications with monitoring of [MASKED] attaining a goal of 2.0-3.0. Initial blood cultures grew staphylococcus, coagulase negative, but subsequent blood cultures reportedly showed no growth. Her sputum culture reportedly grew e.coli and klebseilla and the patient transitioned to a course of augmentin, last dose [MASKED]. Her repeat sputum culture on [MASKED] showed no micro-organisms. On [MASKED], the patient was reported to have diarrhea which was negative for c.diff. Tube feeding changes were undertaken per recommendations of Nutrition to help decrease the diarrhea. In preparation for discharge, the patient was evaluated by physical and occupational therapy and recommendations were made for discharge to a rehabilitation facility. The patient was discharged on HD #9 with stable vital signs. Her white blood cell count had normalized and her hematocrit remained stable at 23.4. She was tolerating her tube feedings via the GJ tube. Her INR at the time of discharge was 1.4. Appointments for follow-up were made with the Orthopedic, Neurosurgery, and Acute care surgery clinics. Medications on Admission: MEDICATIONS: Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild Acetylcysteine 20% [MASKED] mL NEB Q4H:PRN mucus plugging Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Aspirin 81 mg PO DAILY Bisacodyl 10 mg PR QHS:PRN constipation Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID Glargine 12 Units Breakfast Glargine 14 Units Bedtime Insulin SC Sliding Scale using REG Insulin Ipratropium-Albuterol Neb 1 NEB NEB Q6H Levothyroxine Sodium 150 mcg PO DAILY Metoclopramide 10 mg PO QIDACHS Metoprolol Tartrate 12.5 mg PO BID Milk of Magnesia 30 mL PO Q6H:PRN constipation Nystatin Oral Suspension 5 mL PO QID:PRN thrush OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate Pantoprazole 40 mg PO Q24H TiCAGRELOR 90 mg PO BID Duration: [MASKED] [MASKED] MD to order daily dose PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Acetylcysteine 20% [MASKED] mL NEB Q4H:PRN mucous plugging 3. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H last dose [MASKED] 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 5. Aspirin 81 mg PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Lantus (insulin glargine) 14 units subcutaneous BEDTIME 10. LORazepam 1 mg PO Q6H:PRN agitation 11. Metoclopramide 10 mg PO QIDACHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. OxycoDONE Liquid 5 mg PO Q8H:PRN Pain - Moderate hold for increased sedation, resp. rate <8 14. Pantoprazole 40 mg IV Q24H 15. Warfarin 4 mg PO ONCE Duration: 1 Dose 16. insulin glargine 12 subcutaneous Breakfast 17. Levothyroxine Sodium 150 mcg PO DAILY 18. Metoprolol Tartrate 12.5 mg PO BID 19. TiCAGRELOR 90 mg PO BID 20. [MASKED] MD to order daily dose PO DAILY16 daily dose based on daily [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were re-admitted to the hospital from the rehabilitation center with fever, and tachycardia. You were also noted to have an elevated white blood cell count. You underwent a cat scan and you were found to have pneumonia. You were started on antibiotics. Your white blood cell count has normalized and you are preparing to return to the rehabilitation center to regain your strength and mobility. You are being discharged with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids Followup Instructions: [MASKED]
[]
[ "E039", "Y929", "Z794", "E119" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "T82524A: Displacement of infusion catheter, initial encounter", "E46: Unspecified protein-calorie malnutrition", "Z930: Tracheostomy status", "Z931: Gastrostomy status", "B3749: Other urogenital candidiasis", "E039: Hypothyroidism, unspecified", "Y828: Other medical devices associated with adverse incidents", "Y929: Unspecified place or not applicable", "R32: Unspecified urinary incontinence", "Z794: Long term (current) use of insulin", "S12000D: Unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing", "S0240DD: Maxillary fracture, left side, subsequent encounter for fracture with routine healing", "S062X0D: Diffuse traumatic brain injury without loss of consciousness, subsequent encounter", "V892XXD: Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter", "Z6830: Body mass index [BMI]30.0-30.9, adult", "S0219XD: Other fracture of base of skull, subsequent encounter for fracture with routine healing", "S0281XD: Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with routine healing", "S2241XD: Multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing", "S7291XE: Unspecified fracture of right femur, subsequent encounter for open fracture type I or II with routine healing", "S82141D: Displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing", "E119: Type 2 diabetes mellitus without complications" ]
10,058,575
26,633,991
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: ___: 1. Left iliac vein and IVC venogram. 2. Infrarenal retrievable (Denali) IVC filter deployment. 3. Post-filter placement venogram. ___: 1. Open reduction, internal fixation, right femur. 2. Open reduction, internal fixation, left ankle. 3. Open reduction, internal fixation, left distal tib-fib joint ___: Tracheostomy ___: Percutaneous endoscopic gastrostomy tube placement (PEG) ___: Revision ankle fixation with fixation of distal tibia anterolateral corner and refixation of fibula and syndesmosis. ___: Interventional Radiology Conversion of PEG to GJ Tube. History of Present Illness: ___ year old female who presents to ___ ED on ___ after a motor vehicle collision. Upon arrival, a ___ shows right subdural hematoma, right traumatic subarachnoid hemorrhage, as well as a C1 fracture with possible ICA injury. Past Medical History: PMH: DM, hypothyroidism, "unclear liver disease" per family PSH: Unknown Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: General: intubated HEENT: Normocephalic, atraumatic Resp: intubated CV: Regular Rate and Rhythm Abd: Nondistended MSK: shortening and external rotation of right lower extremity with deformity over the thigh. Lateral dislocation of the left ankle, pulses intact, patient spontaneously moves toes. Ecchymosis without bony deformity or crepitus to right elbow Skin: No rash, Warm and dry, No petechiae Neuro: spontaneously moves all extremities, responds to pain with nonpurposeful movement Discharge Physical Exam: GEN: chronically ill-appearing but non-verbally interactive with staff HEENT: NCAT, EOMI, no scleral icterus CV: irregularly irregular rhythm, radial pulses 2+ b/l RESP: breathing comfortably on tracheostomy with humidified air GI: soft, non-TTP, no R/G/D, no masses, left sided GJ Tune EXT: warm and well perfused, LLE in orthopedic booth, Left DL PICC Line, Right hand in protective mitt Pertinent Results: IMAGING: ___: ECG: Baseline artifact. Sinus rhythm. Non-specific repolarization abnormalities. Q-T interval is not well seen as T wave is indistinct but is likely prolonged. No previous tracing available for comparison. ___: CT C-spine: 1. Large hematoma centered in the right carotid space is highly concerning for acute injury to the right carotid artery and urgent CTA of the head and neck is recommended. 2. Avulsion of the alar ligaments at the level of the dens raises concern for craniocervical instability. Acute fractures involving the anterior posterior ring of C1. Difficult to exclude injury to the transverse ligament given asymmetry at C1-2. Small extra-axial hematoma at the level of C1-2. Recommend correlation with MRI. 3. Skullbase and facial fractures are better described on the maxillofacial CT from the same date. ___: CT Head: 1. 4 mm right cerebral subdural hematoma. No significant midline shift. 2. Tiny right cerebral subarachnoid hemorrhage and right frontal vertex contusion. 3. Depressed, comminuted fracture of the right squamous temporal bone (03:24). No associated epidural hematoma. 4. Please refer to same-day CT facial bone and CT C-spine for details regarding facial and cervical spine injuries. ___: CXR: Low-lying ET tube requires approximately 1-1.5 cm retraction for more optimal positioning. Esophageal pH probe and orogastric tubes appear well positioned. ___: Right femur x-ray: Displaced and angulated right midshaft femur fracture, comminuted. ___: CT Chest, Abdomen & Pelvis: 1. Hematoma tracks along the right common carotid artery into the superior mediastinum. Please refer to the CTA head and neck performed on the same date for a complete description of injury to the right carotid artery. 2. Endotracheal tube terminates 1 cm above the carina, as seen on chest x-ray. Slight retraction of the endotracheal tube is recommended. 3. Right quadriceps hematoma is partially seen on this study, which is most likely related to the comminuted femoral shaft fracture better characterized on pelvic and femur radiographs from the same date. Close clinical observation for compartment syndrome is recommended. 4. Minimally displaced posterior right eleventh and twelfth rib fractures. ___: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST: 1. Multiple facial bone fractures, right greater than left with proptotic right globe and right extraconal hematoma. 2. Mild prominence of the right lateral rectus muscle raises potential concern for contusion. Straightening of the right optic nerve should be correlated with vision exam. 3. Bilateral maxillary sinus fractures. 4. Right squamous temporal bone fracture better assessed on same-day head CT. ___: CTA Head & Neck: 1. Complete transection of the right internal carotid artery, about 2 cm above the bifurcation, with extravasation into the adjacent carotid sheath hematoma, causing mass effect on the right jugular vein. The left ICA appears normal without evidence of stenosis, occlusion, or dissection. The vertebral arteries appear normal bilaterally. 2. Irregularity and narrowed caliber of the cavernous segment of the intracranial portions of the right internal carotid artery are concerning for dissection. 3. Distal reconstitution of the intracranial portions of the right ICA is likely from collaterals in the left anterior and posterior circulation. As such, the vessels of the circle of ___ are patent without stenosis, occlusion, or aneurysm formation. 4. Known acute fractures of the left posterior maxillary sinus, anterior and posterior arch of C1, lateral wall of the right orbit as well as small right frontal subdural hematoma are better seen on the same day dedicated CT Head and Maxillofacial exam. 5. Patient is intubated. An oral catheter is also incidentally noted. ___: ELBOW (AP, LAT & OBLIQUE) RIGHT PORT: No Acute fx. ___: Left ankle x-ray: Acute fractures involving the distal fibular shaft and medial malleolus. ___: TIB/FIB (AP & LAT) LEFT: Acute fractures involving the distal shaft fibula and medial malleolus. ___: MRI & MRA BRAIN AND MRA: 1. Stable small right subdural hematoma. 2. Blood within the occipital horns of the lateral ventricles is more conspicuous than on the prior CT, which may be due to differences in modalities. 3. Stable small right superior frontal hemorrhagic contusion versus hemorrhagic diffuse axonal injury. 4. Several punctate foci of slow diffusion at the gray-white junction in the right frontal lobe may represent tiny embolic infarcts or nonhemorrhagic diffuse axonal injury. 5. Small focus of hypointense signal in the left dorsal midbrain on gradient echo images which may represent a chronic microhemorrhage, as there is no associated acute diffusion abnormality. 6. Diffuse bilateral sulcal FLAIR hyperintensity without associated abnormality on gradient echo images may be secondary to intubated status and supplemental oxygen therapy, rather than interval increase in previously minimal subarachnoid hemorrhage. This could be clarified on follow up CT. 7. 16 x 25 mm medially projecting pseudoaneurysm of the distal right cervical internal carotid artery at C2. The internal carotid artery in the internal jugular vein are moderately compressed by the pseudoaneurysm. Distal to the pseudoaneurysm, there is reconstitution of flow in the right internal carotid artery with normal caliber distal to the level of C2, representing improvement compared to ___. 8. Turbulent flow in the proximal basilar artery. 9. Blood within the paranasal sinuses secondary to multiple facial fractures, which are better demonstrated on the ___: CHEST PORT. LINE PLACEM: Compared to a chest radiographs earlier on ___. Tip of the endotracheal tube with the chin elevated is less than 2 cm from the carina. It should be withdrawn 2 cm to avoid unilateral intubation particularly with chin flexion. Left subclavian line ends close to the superior cavoatrial junction. Transesophageal drainage tube loops in the stomach and passes at least as far as the pylorus and out of view. Previous left lower lobe peribronchial opacification has improved. Lungs are essentially clear, heart size normal. No pleural effusion or pneumothorax. ___: KNEE (2 VIEWS) RIGHT : 1. Fracture of the lateral tibial plateau of the knee. 2. Single pin traversing the proximal tibial metadiaphysis. ___: ANKLE (2 VIEWS) RIGHT : 1. Overall improved congruency of the ankle mortise. 2. Resolved posterior displacement but new lateral displacement of the distal fibular fracture. 3. Improved alignment of the medial malleolar fracture. 4. Lateral distal tibial metaphyseal fracture faintly visualized without significant displacement. ___: CT HEAD W/O CONTRAST: 1. Increase in extent of subarachnoid hemorrhage now involving bilateral hemispheres. Persistent right convexity subdural hematoma. ___: CAROTID/CEREBRAL STENTI : Successful restoration of flow into the right cervical internal carotid artery status post dissection with contrast stagnation in the pseudoaneurysm. ___: FEMUR (AP & LAT) RIGHT : In comparison with the study of ___, there has been substantial improvement in the alignment of the comminuted fracture of the midshaft of the femur following the application of traction. Otherwise little change. ___: CXR: Compared to chest radiographs ___. Endotracheal tube, left subclavian line, and esophageal drainage tube are in standard placements. Lungs clear. Heart size normal. No pleural abnormality. ___: CTA PELVIS W&W/O C & RE: 1. Soft tissue stranding surrounding the bilateral common femoral arteries related to bilateral femoral angiograms performed earlier on same day, with no evidence of active arterial or venous extravasation. 2. Small amount of nonocclusive thrombus in the right external iliac vein at the site of a recent femoral central venous catheter. 3. Re- demonstration of a comminuted and displaced right femoral shaft fracture, with no evidence of associated vascular injury. 4. Re- demonstration of a right quadriceps hematoma, with no evidence of active extravasation. 5. A partially visualized right tibial plateau fracture is better evaluated on CT right lower extremity performed on same day. ___: CT LOW EXT W/O C RIGHT: 1. Sagittally oriented, nondisplaced lateral tibial plateau fracture with intra-articular extension. 2. Large knee joint lipohemarthrosis with extensive soft tissue swelling. 3. Subchondral cystic changes of the medial tibiofemoral compartment consistent with degenerative joint disease. 4. External fixation device is noted through the proximal tibia without evidence of hardware complication. ___: CT Head: 1. Stable appearance extensive subarachnoid hemorrhage involving the bilateral cerebral hemispheres and small right frontoparietal subdural hematoma compared to prior same-day CT exam. No new focus of hemorrhage or acute major vascular territory infarction is identified. 2. Multiple known fractures are better assessed on the dedicated CT maxillofacial exam from ___. ___: IVC GRAM/FILTER : Successful deployment of retrievable (Denali) IVC filter ___: EEG: This is an abnormal continuous ICU monitoring study because of diffusely slow background, indicative of a moderate to severe encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. ___: LOWER EXTREMITY FLUORO : Postoperative changes with tibia-fibula arthrodesis, medial malleolar screw and plate screw fixation of the distal fibula. Soft tissue swelling. ___: ANKLE (2 VIEWS) IN O.R.: Postoperative changes with tibia-fibula arthrodesis, medial malleolar screw and plate screw fixation of the distal fibula. Soft tissue swelling. ___: LOWER EXTREMITY FLUORO : Intramedullary rod in place right femur ___: FEMUR (AP & LAT) IN O.R: Intramedullary rod in place right femur ___: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. ___: CT Head: 1. Overall stable study from most recent examination on ___. 2. Unchanged right proptosis. ___: CT LOW EXT W/O C LEFT: 1. Postoperative changes consistent with ORIF of the distal tibia and fibula. A vertically-oriented fracture through the anteromedial tibia is not transfixed by the surgical hardware. No hardware complications detected. 2. Fracture lines remain visible 3. Findings suggestive of mild plantar fasciitis. ___: CXR: Compared to chest radiographs ___. Left subclavian line are probably has migrated into the azygos vein. ETT in standard placement. Transesophageal drainage tube passes into the mid stomach and out of view. Mild left lower lobe atelectasis has developed. Small bilateral pleural effusions are also new. Upper lungs clear. Heart size normal. No pneumothorax. ___: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. ___: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. ___: CXR: Interval improvement in retrocardiac opacity with some residual patchy opacity and probable small left and right pleural effusions. No overt CHF. ___: ELBOW, AP & LAT VIEWS R: There is no fracture. ___: BILAT LOWER EXT VEINS : Completely occlusive thrombus involving all of the posterior tibial and peroneal veins bilaterally. ___: CT SINUS/MANDIBLE/MAXIL: 1. Dental amalgam streak artifact limits study. 2. Grossly stable appearance of multiple facial, right temporal bone, calvarial and C1 fractures. 3. Gas containing fluid collections in the right maxillary sinus and bilateral sphenoid sinuses are non specific, and may represent blood products, acute sinusitis and / or may be related to intubation status. 4. Previously seen right carotid hematoma surrounding right ICA stent now measures up to 2.2 cm. 5. Periodontal disease of multiple maxillary teeth, as described. ___: BILAT UP EXT VEINS US : 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. Bilateral internal jugular veins could not be evaluated due to C-collar. Bilateral cephalic veins were not visualized. ___: LOWER EXTREMITY FLUORO : Several intraoperative images demonstrate placement of hardware within the distal fibula and tibia. This includes 2 syndesmotic screws. There is widening of the superior portion of the tibiotalar joint. No hardware related complications are identified. Total intraservice fluoroscopic time was 19.5 seconds. Please refer to the operative note for additional details. ___: ANKLE (AP, MORTISE & LA : Several intraoperative images demonstrate placement of hardware within the distal fibula and tibia. This includes 2 syndesmotic screws. There is widening of the superior portion of the tibiotalar joint. No hardware related complications are identified. Total intraservice fluoroscopic time was 19.5 seconds. Please refer to the operative note for additional details. ___: CT HEAD W/ & W/O CONTRA : 1. Compared with the head CT from ___, no new acute intracranial hemorrhage or large vascular territorial infarction. 2. Evolving bilateral subarachnoid hemorrhages and right subdural hematoma, which have become less conspicuous by imaging. 3. Small amount of residual intraventricular hemorrhage in the occipital horn of the left lateral ventricle. 4. Multiple known facial, right temporal bone, and calvarial fractures were better characterized on the CT facial bone study from ___. ___: CHEST (PORTABLE AP) : Comparison to ___. No relevant change. The tracheostomy tube and the left PICC line are stable. Borderline size of the heart. No pneumonia, no pulmonary edema, no pleural effusions. No pneumothorax. ___: FEMUR (AP & LAT) RIGHT: Interval internal fixation, with some callus formation across mid femoral fracture. ___ 05:41AM BLOOD WBC-8.7 RBC-2.66* Hgb-7.4* Hct-25.8* MCV-97 MCH-27.8 MCHC-28.7* RDW-16.3* RDWSD-58.2* Plt ___ ___ 08:28AM BLOOD ___ ___ 05:41AM BLOOD ___ ___ 05:50AM BLOOD ___ ___ 05:41AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-145 K-3.8 Cl-105 HCO3-24 AnGap-20 ___ 05:41AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9 ___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: ICU COURSE: Ms. ___ was admitted to the ___ after an MVC. Trauma workup showed multiple lower extremity fractures, b/l facial fractures, SDH, SAH & IPH & right ICA transection. N: She went to the OR with neurosurgery emergently for a right ICA stent and postop, was started on aspirin and ticagrelor for dual antiplatelet therapy. Her SAH was noted to increase in size shortly after arrival to the TSICU but no intervention was performed by neurosurgery. Her neuro exam remained poor but stable. CV: She did require vasopressors during the initial part of her hospitalization but was eventually able to wean off pressors and remain hemodynamically stable Pulm: Pt was intubated at the scene due to concern for head injury. Due to her poor neurologic status, she eventually underwent placement of a tracheostomy and tolerated this well. She was also treated with ceftriaxone for E.coli VAP GI: Due to acute & critical illness, she was initially kept NPO. Once appropriate for feeding, she underwent placement of a PEG tube and her tube feeds were advanced to goal and tolerated well. Endocrine: Her blood glucose levels were monitored and treated appropriately with SSI Heme: After her right ICA stent, she was started on dual antiplatelet therapy. She was also started on a heparin gtt for ___ DVT which was eventually transitioned to coumadin. She also had a prophylactic IVC filter placed. MSK: She had multiple fractures of her lower extremities and underwent ORIF of her right femur and left ankle with Orthopedic Surgery. The left ankle ORIF required revision but she tolerated all these procedures well with no complications. She had c1 fractures for which she was kept in a c-collar. ID: She was persistently febrile. Fever workup revealed E.coli which was treated with ceftriaxone & ___ DVT as possible causes. However, the fevers persisted and it was thought that there was possibly a central component to them. Her WBC eventually normalized. FLOOR COURSE: N: The patient remained alert since being transferred to the floor. The patient was able to give a thumbs up on her right hand when asked and was moving her right sided extremities, but remained unable to move on her left side. The son was spoken with bedside and reports she has attempted to talk with him on a daily basis. Respiratory therapy downsized and adjusted her tracheostomy tube on ___ and the patient was able to minimally verbally communicate with staff and family. CV: The patient remained stable from a cardiac standpoint. EKGs were checked daily to monitor QTc when starting reglan and antibiotics that prolong the QT interval. Pulm: On ___, the patient had emesis soon after receiving her AM medications and there was concern for aspiration. The patient desaturated to the high 80% and was suctioned and saturation returned to high ___ on TM. Chest x-ray was ordered and sputum cultures were obtained which demonstrated e.coli and she was again started on IV ceftriaxone for VAP. Repeat imaging of the next several days demonstrated a large RLL Pneumonia for which she was started on Vancomycin, Zosyn and Fluconazole. Her Vancomycin levels were difficult to control and required frequent Vanco. Trough levels to titrate her doses to a therapeutic level. Her antibiotics were discontinued prior to her discharge and she remained afebrile in the several days leading up to her discharge. GI: The patient continued on tube feeds. Her rate was decreased from an original goal of 60 mL/hr to ___ m/L per hour in the presence of aspiration risk. On ___, her PEG tube was converted to a GJ tube by the ___ team and she was restarted on tube feeds with the previous goal of 35. Endocrine: Her blood glucose levels were monitored and treated appropriately with SSI Heme: After her right ICA stent, she was started on dual antiplatelet therapy. She was also started on a heparin gtt for ___ DVT which was eventually transitioned to coumadin. She also had a prophylactic IVC filter placed by ___ shortly after admission. MSK: She had multiple fractures of her lower extremities and underwent ORIF of her right femur and left ankle with Orthopedic Surgery. The left ankle ORIF required revision but she tolerated all these procedures well with no complications. She had C1 fractures for which she was kept in a c-collar. ID: She was persistently febrile. Fever workup revealed E.coli which was treated with ceftriaxone & ___ DVT as possible causes. However, the fevers persisted and it was thought that there was possibly a central component to them. Her WBC eventually normalized. She was later found to have a RLL Pneumonia likely secondary to a previous aspiration event. She was started on the appropriate antibiotics as above and her intermittent fevers became less frequent. On HD48, the patient was deemed clinically stable and appropriate for discharge to a rehabilitation facility with appropriate follow up clinic visits scheduled. Medications on Admission: Unknown Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN mucus plugging 3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 4. Aspirin 81 mg PO DAILY 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID 7. Glargine 12 Units Breakfast Glargine 14 Units Bedtime Insulin SC Sliding Scale using REG Insulin 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Levothyroxine Sodium 150 mcg PO DAILY 10. Metoclopramide 10 mg PO QIDACHS 11. Metoprolol Tartrate 12.5 mg PO BID 12. Milk of Magnesia 30 mL PO Q6H:PRN constipation 13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 14. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg/5 mL 5 mL per J Tube every eight (8) hours Refills:*0 15. Pantoprazole 40 mg PO Q24H 16. TiCAGRELOR 90 mg PO BID Duration: 3 Months 17. ___ MD to order daily dose PO DAILY16 18. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Polytrauma: [] Right subdural hematoma [] Right traumatic subarachnoid hemorrhage [] C1 fracture [] Complete transection of the right internal carotid artery [] Right orbit lateral wall fracture [] Acute fracture of the left posterior maxillary sinus [] Temporal bone fracture [] Right side rib fractures (___) [] Right femur fracture [] Right tibial plateau fracture [] Left ankle fracture [] Right external iliac vein thrombosis Secondary: [] Malnutrition secondary to dysphagia [] Hospital-acquired pneumonia [] Central line associated blood stream infection [] Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, You were ___ to ___ after a motor vehicle collision. You sustained serious injuries, including bleeding in your head (traumatic brain injury), injury to your right carotid artery, and multiple fractures to your face, ribs, right leg and left ankle. Regarding the life threatening injury to your right carotid artery, you were first taken to the Interventional Radiology team and Neuroendovascular Team for stenting and IVC filter placement for the right internal carotid artery transection and right external iliac vein thrombosis. To protect the stent and repair to your carotid artery, you should remain on Aspirin and Ticagrelor (Brilinta) for the next 3 months or until instructed otherwise. Neurosurgery was consulted regarding your traumatic brain injury and your C1 Vertebral fracture and recommended that you continue to wear the hard C-Collar for the next ___ months until you follow up with Dr. ___ in clinic as an outpatient. Regarding your multiple Orthopedic injuries, you received an Open Reduction and Internal Fixation of your femur and ankle fractures and will require substantial rehab efforts during your recovery. You should not bear any weight on your right leg and may bear weight on your left leg as tolerated. You also required the placement of a tracheostomy tube which assists in your breathing. This tube will need to remain in for some time. The tracheostomy tube should be changed to a smaller tube that will allow you to speak with some practice. The rehab facility will assist in this issue and should do so within ___ weeks of your discharge. Due to your inability to safely swallow liquids or solid foods while in the hospital, we placed a feeding tube that advances from your skin into your stomach and proximal portions of your small intestines. This will allow your medical teams to administer tube feeds to maintain your nutrition until you are deemed safe and appropriate to take nutrition by your mouth. The tube will be maintained by your rehab facility and should be frequently flushed to avoid clogging. 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: - non-weight bearing left lower extremity, weight-bearing as tolerated right lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - You will need to be on several anti-platelet and anticoagulating medications to protect from blood clots and injury to your recently fixed carotid artery injury. You will need to take Coumadin daily for the foreseeable future with a goal INR of 2.0-3.0. As above, you should also take Aspirin and Ticagrelor (Brilinta) for 3 months. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - All sutures and staples have been removed - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet 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. Good Luck! Followup Instructions: ___
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [MASKED]: 1. Left iliac vein and IVC venogram. 2. Infrarenal retrievable (Denali) IVC filter deployment. 3. Post-filter placement venogram. [MASKED]: 1. Open reduction, internal fixation, right femur. 2. Open reduction, internal fixation, left ankle. 3. Open reduction, internal fixation, left distal tib-fib joint [MASKED]: Tracheostomy [MASKED]: Percutaneous endoscopic gastrostomy tube placement (PEG) [MASKED]: Revision ankle fixation with fixation of distal tibia anterolateral corner and refixation of fibula and syndesmosis. [MASKED]: Interventional Radiology Conversion of PEG to GJ Tube. History of Present Illness: [MASKED] year old female who presents to [MASKED] ED on [MASKED] after a motor vehicle collision. Upon arrival, a [MASKED] shows right subdural hematoma, right traumatic subarachnoid hemorrhage, as well as a C1 fracture with possible ICA injury. Past Medical History: PMH: DM, hypothyroidism, "unclear liver disease" per family PSH: Unknown Social History: [MASKED] Family History: non-contributory Physical Exam: Admission Physical Exam: General: intubated HEENT: Normocephalic, atraumatic Resp: intubated CV: Regular Rate and Rhythm Abd: Nondistended MSK: shortening and external rotation of right lower extremity with deformity over the thigh. Lateral dislocation of the left ankle, pulses intact, patient spontaneously moves toes. Ecchymosis without bony deformity or crepitus to right elbow Skin: No rash, Warm and dry, No petechiae Neuro: spontaneously moves all extremities, responds to pain with nonpurposeful movement Discharge Physical Exam: GEN: chronically ill-appearing but non-verbally interactive with staff HEENT: NCAT, EOMI, no scleral icterus CV: irregularly irregular rhythm, radial pulses 2+ b/l RESP: breathing comfortably on tracheostomy with humidified air GI: soft, non-TTP, no R/G/D, no masses, left sided GJ Tune EXT: warm and well perfused, LLE in orthopedic booth, Left DL PICC Line, Right hand in protective mitt Pertinent Results: IMAGING: [MASKED]: ECG: Baseline artifact. Sinus rhythm. Non-specific repolarization abnormalities. Q-T interval is not well seen as T wave is indistinct but is likely prolonged. No previous tracing available for comparison. [MASKED]: CT C-spine: 1. Large hematoma centered in the right carotid space is highly concerning for acute injury to the right carotid artery and urgent CTA of the head and neck is recommended. 2. Avulsion of the alar ligaments at the level of the dens raises concern for craniocervical instability. Acute fractures involving the anterior posterior ring of C1. Difficult to exclude injury to the transverse ligament given asymmetry at C1-2. Small extra-axial hematoma at the level of C1-2. Recommend correlation with MRI. 3. Skullbase and facial fractures are better described on the maxillofacial CT from the same date. [MASKED]: CT Head: 1. 4 mm right cerebral subdural hematoma. No significant midline shift. 2. Tiny right cerebral subarachnoid hemorrhage and right frontal vertex contusion. 3. Depressed, comminuted fracture of the right squamous temporal bone (03:24). No associated epidural hematoma. 4. Please refer to same-day CT facial bone and CT C-spine for details regarding facial and cervical spine injuries. [MASKED]: CXR: Low-lying ET tube requires approximately 1-1.5 cm retraction for more optimal positioning. Esophageal pH probe and orogastric tubes appear well positioned. [MASKED]: Right femur x-ray: Displaced and angulated right midshaft femur fracture, comminuted. [MASKED]: CT Chest, Abdomen & Pelvis: 1. Hematoma tracks along the right common carotid artery into the superior mediastinum. Please refer to the CTA head and neck performed on the same date for a complete description of injury to the right carotid artery. 2. Endotracheal tube terminates 1 cm above the carina, as seen on chest x-ray. Slight retraction of the endotracheal tube is recommended. 3. Right quadriceps hematoma is partially seen on this study, which is most likely related to the comminuted femoral shaft fracture better characterized on pelvic and femur radiographs from the same date. Close clinical observation for compartment syndrome is recommended. 4. Minimally displaced posterior right eleventh and twelfth rib fractures. [MASKED]: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST: 1. Multiple facial bone fractures, right greater than left with proptotic right globe and right extraconal hematoma. 2. Mild prominence of the right lateral rectus muscle raises potential concern for contusion. Straightening of the right optic nerve should be correlated with vision exam. 3. Bilateral maxillary sinus fractures. 4. Right squamous temporal bone fracture better assessed on same-day head CT. [MASKED]: CTA Head & Neck: 1. Complete transection of the right internal carotid artery, about 2 cm above the bifurcation, with extravasation into the adjacent carotid sheath hematoma, causing mass effect on the right jugular vein. The left ICA appears normal without evidence of stenosis, occlusion, or dissection. The vertebral arteries appear normal bilaterally. 2. Irregularity and narrowed caliber of the cavernous segment of the intracranial portions of the right internal carotid artery are concerning for dissection. 3. Distal reconstitution of the intracranial portions of the right ICA is likely from collaterals in the left anterior and posterior circulation. As such, the vessels of the circle of [MASKED] are patent without stenosis, occlusion, or aneurysm formation. 4. Known acute fractures of the left posterior maxillary sinus, anterior and posterior arch of C1, lateral wall of the right orbit as well as small right frontal subdural hematoma are better seen on the same day dedicated CT Head and Maxillofacial exam. 5. Patient is intubated. An oral catheter is also incidentally noted. [MASKED]: ELBOW (AP, LAT & OBLIQUE) RIGHT PORT: No Acute fx. [MASKED]: Left ankle x-ray: Acute fractures involving the distal fibular shaft and medial malleolus. [MASKED]: TIB/FIB (AP & LAT) LEFT: Acute fractures involving the distal shaft fibula and medial malleolus. [MASKED]: MRI & MRA BRAIN AND MRA: 1. Stable small right subdural hematoma. 2. Blood within the occipital horns of the lateral ventricles is more conspicuous than on the prior CT, which may be due to differences in modalities. 3. Stable small right superior frontal hemorrhagic contusion versus hemorrhagic diffuse axonal injury. 4. Several punctate foci of slow diffusion at the gray-white junction in the right frontal lobe may represent tiny embolic infarcts or nonhemorrhagic diffuse axonal injury. 5. Small focus of hypointense signal in the left dorsal midbrain on gradient echo images which may represent a chronic microhemorrhage, as there is no associated acute diffusion abnormality. 6. Diffuse bilateral sulcal FLAIR hyperintensity without associated abnormality on gradient echo images may be secondary to intubated status and supplemental oxygen therapy, rather than interval increase in previously minimal subarachnoid hemorrhage. This could be clarified on follow up CT. 7. 16 x 25 mm medially projecting pseudoaneurysm of the distal right cervical internal carotid artery at C2. The internal carotid artery in the internal jugular vein are moderately compressed by the pseudoaneurysm. Distal to the pseudoaneurysm, there is reconstitution of flow in the right internal carotid artery with normal caliber distal to the level of C2, representing improvement compared to [MASKED]. 8. Turbulent flow in the proximal basilar artery. 9. Blood within the paranasal sinuses secondary to multiple facial fractures, which are better demonstrated on the [MASKED]: CHEST PORT. LINE PLACEM: Compared to a chest radiographs earlier on [MASKED]. Tip of the endotracheal tube with the chin elevated is less than 2 cm from the carina. It should be withdrawn 2 cm to avoid unilateral intubation particularly with chin flexion. Left subclavian line ends close to the superior cavoatrial junction. Transesophageal drainage tube loops in the stomach and passes at least as far as the pylorus and out of view. Previous left lower lobe peribronchial opacification has improved. Lungs are essentially clear, heart size normal. No pleural effusion or pneumothorax. [MASKED]: KNEE (2 VIEWS) RIGHT : 1. Fracture of the lateral tibial plateau of the knee. 2. Single pin traversing the proximal tibial metadiaphysis. [MASKED]: ANKLE (2 VIEWS) RIGHT : 1. Overall improved congruency of the ankle mortise. 2. Resolved posterior displacement but new lateral displacement of the distal fibular fracture. 3. Improved alignment of the medial malleolar fracture. 4. Lateral distal tibial metaphyseal fracture faintly visualized without significant displacement. [MASKED]: CT HEAD W/O CONTRAST: 1. Increase in extent of subarachnoid hemorrhage now involving bilateral hemispheres. Persistent right convexity subdural hematoma. [MASKED]: CAROTID/CEREBRAL STENTI : Successful restoration of flow into the right cervical internal carotid artery status post dissection with contrast stagnation in the pseudoaneurysm. [MASKED]: FEMUR (AP & LAT) RIGHT : In comparison with the study of [MASKED], there has been substantial improvement in the alignment of the comminuted fracture of the midshaft of the femur following the application of traction. Otherwise little change. [MASKED]: CXR: Compared to chest radiographs [MASKED]. Endotracheal tube, left subclavian line, and esophageal drainage tube are in standard placements. Lungs clear. Heart size normal. No pleural abnormality. [MASKED]: CTA PELVIS W&W/O C & RE: 1. Soft tissue stranding surrounding the bilateral common femoral arteries related to bilateral femoral angiograms performed earlier on same day, with no evidence of active arterial or venous extravasation. 2. Small amount of nonocclusive thrombus in the right external iliac vein at the site of a recent femoral central venous catheter. 3. Re- demonstration of a comminuted and displaced right femoral shaft fracture, with no evidence of associated vascular injury. 4. Re- demonstration of a right quadriceps hematoma, with no evidence of active extravasation. 5. A partially visualized right tibial plateau fracture is better evaluated on CT right lower extremity performed on same day. [MASKED]: CT LOW EXT W/O C RIGHT: 1. Sagittally oriented, nondisplaced lateral tibial plateau fracture with intra-articular extension. 2. Large knee joint lipohemarthrosis with extensive soft tissue swelling. 3. Subchondral cystic changes of the medial tibiofemoral compartment consistent with degenerative joint disease. 4. External fixation device is noted through the proximal tibia without evidence of hardware complication. [MASKED]: CT Head: 1. Stable appearance extensive subarachnoid hemorrhage involving the bilateral cerebral hemispheres and small right frontoparietal subdural hematoma compared to prior same-day CT exam. No new focus of hemorrhage or acute major vascular territory infarction is identified. 2. Multiple known fractures are better assessed on the dedicated CT maxillofacial exam from [MASKED]. [MASKED]: IVC GRAM/FILTER : Successful deployment of retrievable (Denali) IVC filter [MASKED]: EEG: This is an abnormal continuous ICU monitoring study because of diffusely slow background, indicative of a moderate to severe encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. [MASKED]: LOWER EXTREMITY FLUORO : Postoperative changes with tibia-fibula arthrodesis, medial malleolar screw and plate screw fixation of the distal fibula. Soft tissue swelling. [MASKED]: ANKLE (2 VIEWS) IN O.R.: Postoperative changes with tibia-fibula arthrodesis, medial malleolar screw and plate screw fixation of the distal fibula. Soft tissue swelling. [MASKED]: LOWER EXTREMITY FLUORO : Intramedullary rod in place right femur [MASKED]: FEMUR (AP & LAT) IN O.R: Intramedullary rod in place right femur [MASKED]: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. [MASKED]: CT Head: 1. Overall stable study from most recent examination on [MASKED]. 2. Unchanged right proptosis. [MASKED]: CT LOW EXT W/O C LEFT: 1. Postoperative changes consistent with ORIF of the distal tibia and fibula. A vertically-oriented fracture through the anteromedial tibia is not transfixed by the surgical hardware. No hardware complications detected. 2. Fracture lines remain visible 3. Findings suggestive of mild plantar fasciitis. [MASKED]: CXR: Compared to chest radiographs [MASKED]. Left subclavian line are probably has migrated into the azygos vein. ETT in standard placement. Transesophageal drainage tube passes into the mid stomach and out of view. Mild left lower lobe atelectasis has developed. Small bilateral pleural effusions are also new. Upper lungs clear. Heart size normal. No pneumothorax. [MASKED]: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. [MASKED]: EEG: This is an abnormal continuous ICU monitoring study because of diffuse slowing of the background, indicative of a moderate encephalopathy, which is non-specific as to etiology. There are no focal abnormalities, electrographic seizures or epileptiform discharges. Compared to the prior day's recording, there are no significant changes. [MASKED]: CXR: Interval improvement in retrocardiac opacity with some residual patchy opacity and probable small left and right pleural effusions. No overt CHF. [MASKED]: ELBOW, AP & LAT VIEWS R: There is no fracture. [MASKED]: BILAT LOWER EXT VEINS : Completely occlusive thrombus involving all of the posterior tibial and peroneal veins bilaterally. [MASKED]: CT SINUS/MANDIBLE/MAXIL: 1. Dental amalgam streak artifact limits study. 2. Grossly stable appearance of multiple facial, right temporal bone, calvarial and C1 fractures. 3. Gas containing fluid collections in the right maxillary sinus and bilateral sphenoid sinuses are non specific, and may represent blood products, acute sinusitis and / or may be related to intubation status. 4. Previously seen right carotid hematoma surrounding right ICA stent now measures up to 2.2 cm. 5. Periodontal disease of multiple maxillary teeth, as described. [MASKED]: BILAT UP EXT VEINS US : 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. Bilateral internal jugular veins could not be evaluated due to C-collar. Bilateral cephalic veins were not visualized. [MASKED]: LOWER EXTREMITY FLUORO : Several intraoperative images demonstrate placement of hardware within the distal fibula and tibia. This includes 2 syndesmotic screws. There is widening of the superior portion of the tibiotalar joint. No hardware related complications are identified. Total intraservice fluoroscopic time was 19.5 seconds. Please refer to the operative note for additional details. [MASKED]: ANKLE (AP, MORTISE & LA : Several intraoperative images demonstrate placement of hardware within the distal fibula and tibia. This includes 2 syndesmotic screws. There is widening of the superior portion of the tibiotalar joint. No hardware related complications are identified. Total intraservice fluoroscopic time was 19.5 seconds. Please refer to the operative note for additional details. [MASKED]: CT HEAD W/ & W/O CONTRA : 1. Compared with the head CT from [MASKED], no new acute intracranial hemorrhage or large vascular territorial infarction. 2. Evolving bilateral subarachnoid hemorrhages and right subdural hematoma, which have become less conspicuous by imaging. 3. Small amount of residual intraventricular hemorrhage in the occipital horn of the left lateral ventricle. 4. Multiple known facial, right temporal bone, and calvarial fractures were better characterized on the CT facial bone study from [MASKED]. [MASKED]: CHEST (PORTABLE AP) : Comparison to [MASKED]. No relevant change. The tracheostomy tube and the left PICC line are stable. Borderline size of the heart. No pneumonia, no pulmonary edema, no pleural effusions. No pneumothorax. [MASKED]: FEMUR (AP & LAT) RIGHT: Interval internal fixation, with some callus formation across mid femoral fracture. [MASKED] 05:41AM BLOOD WBC-8.7 RBC-2.66* Hgb-7.4* Hct-25.8* MCV-97 MCH-27.8 MCHC-28.7* RDW-16.3* RDWSD-58.2* Plt [MASKED] [MASKED] 08:28AM BLOOD [MASKED] [MASKED] 05:41AM BLOOD [MASKED] [MASKED] 05:50AM BLOOD [MASKED] [MASKED] 05:41AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-145 K-3.8 Cl-105 HCO3-24 AnGap-20 [MASKED] 05:41AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9 [MASKED] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: ICU COURSE: Ms. [MASKED] was admitted to the [MASKED] after an MVC. Trauma workup showed multiple lower extremity fractures, b/l facial fractures, SDH, SAH & IPH & right ICA transection. N: She went to the OR with neurosurgery emergently for a right ICA stent and postop, was started on aspirin and ticagrelor for dual antiplatelet therapy. Her SAH was noted to increase in size shortly after arrival to the TSICU but no intervention was performed by neurosurgery. Her neuro exam remained poor but stable. CV: She did require vasopressors during the initial part of her hospitalization but was eventually able to wean off pressors and remain hemodynamically stable Pulm: Pt was intubated at the scene due to concern for head injury. Due to her poor neurologic status, she eventually underwent placement of a tracheostomy and tolerated this well. She was also treated with ceftriaxone for E.coli VAP GI: Due to acute & critical illness, she was initially kept NPO. Once appropriate for feeding, she underwent placement of a PEG tube and her tube feeds were advanced to goal and tolerated well. Endocrine: Her blood glucose levels were monitored and treated appropriately with SSI Heme: After her right ICA stent, she was started on dual antiplatelet therapy. She was also started on a heparin gtt for [MASKED] DVT which was eventually transitioned to coumadin. She also had a prophylactic IVC filter placed. MSK: She had multiple fractures of her lower extremities and underwent ORIF of her right femur and left ankle with Orthopedic Surgery. The left ankle ORIF required revision but she tolerated all these procedures well with no complications. She had c1 fractures for which she was kept in a c-collar. ID: She was persistently febrile. Fever workup revealed E.coli which was treated with ceftriaxone & [MASKED] DVT as possible causes. However, the fevers persisted and it was thought that there was possibly a central component to them. Her WBC eventually normalized. FLOOR COURSE: N: The patient remained alert since being transferred to the floor. The patient was able to give a thumbs up on her right hand when asked and was moving her right sided extremities, but remained unable to move on her left side. The son was spoken with bedside and reports she has attempted to talk with him on a daily basis. Respiratory therapy downsized and adjusted her tracheostomy tube on [MASKED] and the patient was able to minimally verbally communicate with staff and family. CV: The patient remained stable from a cardiac standpoint. EKGs were checked daily to monitor QTc when starting reglan and antibiotics that prolong the QT interval. Pulm: On [MASKED], the patient had emesis soon after receiving her AM medications and there was concern for aspiration. The patient desaturated to the high 80% and was suctioned and saturation returned to high [MASKED] on TM. Chest x-ray was ordered and sputum cultures were obtained which demonstrated e.coli and she was again started on IV ceftriaxone for VAP. Repeat imaging of the next several days demonstrated a large RLL Pneumonia for which she was started on Vancomycin, Zosyn and Fluconazole. Her Vancomycin levels were difficult to control and required frequent Vanco. Trough levels to titrate her doses to a therapeutic level. Her antibiotics were discontinued prior to her discharge and she remained afebrile in the several days leading up to her discharge. GI: The patient continued on tube feeds. Her rate was decreased from an original goal of 60 mL/hr to [MASKED] m/L per hour in the presence of aspiration risk. On [MASKED], her PEG tube was converted to a GJ tube by the [MASKED] team and she was restarted on tube feeds with the previous goal of 35. Endocrine: Her blood glucose levels were monitored and treated appropriately with SSI Heme: After her right ICA stent, she was started on dual antiplatelet therapy. She was also started on a heparin gtt for [MASKED] DVT which was eventually transitioned to coumadin. She also had a prophylactic IVC filter placed by [MASKED] shortly after admission. MSK: She had multiple fractures of her lower extremities and underwent ORIF of her right femur and left ankle with Orthopedic Surgery. The left ankle ORIF required revision but she tolerated all these procedures well with no complications. She had C1 fractures for which she was kept in a c-collar. ID: She was persistently febrile. Fever workup revealed E.coli which was treated with ceftriaxone & [MASKED] DVT as possible causes. However, the fevers persisted and it was thought that there was possibly a central component to them. Her WBC eventually normalized. She was later found to have a RLL Pneumonia likely secondary to a previous aspiration event. She was started on the appropriate antibiotics as above and her intermittent fevers became less frequent. On HD48, the patient was deemed clinically stable and appropriate for discharge to a rehabilitation facility with appropriate follow up clinic visits scheduled. Medications on Admission: Unknown Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 2. Acetylcysteine 20% [MASKED] mL NEB Q4H:PRN mucus plugging 3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 4. Aspirin 81 mg PO DAILY 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID 7. Glargine 12 Units Breakfast Glargine 14 Units Bedtime Insulin SC Sliding Scale using REG Insulin 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. Levothyroxine Sodium 150 mcg PO DAILY 10. Metoclopramide 10 mg PO QIDACHS 11. Metoprolol Tartrate 12.5 mg PO BID 12. Milk of Magnesia 30 mL PO Q6H:PRN constipation 13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 14. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg/5 mL 5 mL per J Tube every eight (8) hours Refills:*0 15. Pantoprazole 40 mg PO Q24H 16. TiCAGRELOR 90 mg PO BID Duration: 3 Months 17. [MASKED] MD to order daily dose PO DAILY16 18. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Polytrauma: [] Right subdural hematoma [] Right traumatic subarachnoid hemorrhage [] C1 fracture [] Complete transection of the right internal carotid artery [] Right orbit lateral wall fracture [] Acute fracture of the left posterior maxillary sinus [] Temporal bone fracture [] Right side rib fractures ([MASKED]) [] Right femur fracture [] Right tibial plateau fracture [] Left ankle fracture [] Right external iliac vein thrombosis Secondary: [] Malnutrition secondary to dysphagia [] Hospital-acquired pneumonia [] Central line associated blood stream infection [] Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [MASKED], You were [MASKED] to [MASKED] after a motor vehicle collision. You sustained serious injuries, including bleeding in your head (traumatic brain injury), injury to your right carotid artery, and multiple fractures to your face, ribs, right leg and left ankle. Regarding the life threatening injury to your right carotid artery, you were first taken to the Interventional Radiology team and Neuroendovascular Team for stenting and IVC filter placement for the right internal carotid artery transection and right external iliac vein thrombosis. To protect the stent and repair to your carotid artery, you should remain on Aspirin and Ticagrelor (Brilinta) for the next 3 months or until instructed otherwise. Neurosurgery was consulted regarding your traumatic brain injury and your C1 Vertebral fracture and recommended that you continue to wear the hard C-Collar for the next [MASKED] months until you follow up with Dr. [MASKED] in clinic as an outpatient. Regarding your multiple Orthopedic injuries, you received an Open Reduction and Internal Fixation of your femur and ankle fractures and will require substantial rehab efforts during your recovery. You should not bear any weight on your right leg and may bear weight on your left leg as tolerated. You also required the placement of a tracheostomy tube which assists in your breathing. This tube will need to remain in for some time. The tracheostomy tube should be changed to a smaller tube that will allow you to speak with some practice. The rehab facility will assist in this issue and should do so within [MASKED] weeks of your discharge. Due to your inability to safely swallow liquids or solid foods while in the hospital, we placed a feeding tube that advances from your skin into your stomach and proximal portions of your small intestines. This will allow your medical teams to administer tube feeds to maintain your nutrition until you are deemed safe and appropriate to take nutrition by your mouth. The tube will be maintained by your rehab facility and should be frequently flushed to avoid clogging. 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: - non-weight bearing left lower extremity, weight-bearing as tolerated right lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - You will need to be on several anti-platelet and anticoagulating medications to protect from blood clots and injury to your recently fixed carotid artery injury. You will need to take Coumadin daily for the foreseeable future with a goal INR of 2.0-3.0. As above, you should also take Aspirin and Ticagrelor (Brilinta) for 3 months. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - All sutures and staples have been removed - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet 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. Good Luck! Followup Instructions: [MASKED]
[]
[ "E1165", "N390", "E039", "Y92230", "D649" ]
[ "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "S15021A: Major laceration of right carotid artery, initial encounter", "S12001A: Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture", "J95851: Ventilator associated pneumonia", "S72301A: Unspecified fracture of shaft of right femur, initial encounter for closed fracture", "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "E1165: Type 2 diabetes mellitus with hyperglycemia", "S0240DA: Maxillary fracture, left side, initial encounter for closed fracture", "S32018A: Other fracture of first lumbar vertebra, initial encounter for closed fracture", "I82421: Acute embolism and thrombosis of right iliac vein", "S82144A: Nondisplaced bicondylar fracture of right tibia, initial encounter for closed fracture", "N390: Urinary tract infection, site not specified", "E46: Unspecified protein-calorie malnutrition", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "S0219XA: Other fracture of base of skull, initial encounter for closed fracture", "V4949XA: Driver injured in collision with other motor vehicles in traffic accident, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S82832A: Other fracture of upper and lower end of left fibula, initial encounter for closed fracture", "S8252XA: Displaced fracture of medial malleolus of left tibia, initial encounter for closed fracture", "S0281XA: Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture", "E039: Hypothyroidism, unspecified", "Z781: Physical restraint status", "S062X9A: Diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "B999: Unspecified infectious disease", "D649: Anemia, unspecified" ]