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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / Gadolinium-Containing Contrast Media Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of pancreatitis, presenting with significant abdominal pain and admitted for chronic pancreatitis flare. He endorses two weeks of abdominal pain, typically relieved by nighttime hydrocodone. He presented to his local ER in ___ twice over the past two weeks, treated with IV nausea and pain medications, and subsequently discharged. He presented to ___ today because his pain has worsened over the past few days and he has run out of home PO opiates. He endorses RUQ pain, epigastric pain, nausea, and vomiting, typical of his pancreatitis. Chart review shows he had cholecystectomy ___ c/b bile leak s/p stent placement that was removed a month later. After this he developed recurrent RUQ pain and was hospitalized at ___ multiple times for acute pancreatitis (one time confirmed by CT A/P, other time lipase >6000). Extensive workup including ex lap ___ to assess surgical site unrevealing. No known etiology of his pancreatitis. EUS ___ showed acute and chronic pancreatitis possibly autoimmune though MRCP showed no evidence of autoimmune pancreatitis and IgG levels normal. In the ED, initial VS were 97.2 67 127/93 16 99% RA. Labs notable for normal CBC, normal BMP, normal LFTS, and normal lipase. The patient received IV LR, IV Zofran x 2, IV dilaudid .25 x 1, .5 x 1, and 1 mg x 1. He was seen by GI who recommended IV fluids, IV Zofran, and IV pain control and admission to ___ ___. Upon arrival to the floor, the patient tells the story as follows. He reports a two week worsening of his pain, nausea, and vomiting. The vomiting is not typically of his pancreatitis flares. He presented to ___ and was given a prescription for hydrocodone-acetaminophen, which he has since run out of. He ate breakfast yesterday, but reports a decrease in appetite. He denies fevers, but endorses chills. He reports that his pain has decreased to a ___ but that he still has shooting intermittent pains. He endorses some radiation to his chest which is typical for him and denies shortness of breath. He has gained weight since his last discharge. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Chronic GERD Tubular adenoma of colon ___ GERD ___ Pancreatitis ___ Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: ___: ERCP stent removal ERCP duct stent placement ___ CCY ___ ERCP to remove duct calculi ___ Elbow arthrosopy/surgery ___ reattached tendon Orthopedic surgery ___ - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries ___ and ___ Social History: ___ Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had ___ disease. MGM had heart disease and died at age ___. PGM had a malignant tumor breast and DM. She died at age ___. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Mucous membranes dry CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, tender to palpation in the RUQ and epigastric area, no rebound or guarding MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs EXT: no edema SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect The patient was examined on day of discharge. Pertinent Results: ADMISSION/SIGNIFICANT LABS: ======================== ___ 08:25PM BLOOD WBC-9.2 RBC-5.24 Hgb-15.0 Hct-45.0 MCV-86 MCH-28.6 MCHC-33.3 RDW-13.2 RDWSD-40.5 Plt ___ ___ 08:25PM BLOOD Glucose-91 UreaN-16 Creat-1.0 Na-142 K-4.0 Cl-105 HCO3-22 AnGap-15 ___ 08:25PM BLOOD ALT-25 AST-18 AlkPhos-114 TotBili-0.4 MICRO: ===== none IMAGING/OTHER STUDIES: ==================== CT a/p ___. Trace peripancreatic stranding and indistinctness of the pancreatic neck and head may suggest mild acute pancreatitis. 2. No evidence of fluid collection, vascular injury, or necrosis. 3. No other acute process in the abdomen pelvis. Normal appendix. LABS ON DISCHARGE: ================= ___ 05:15AM BLOOD WBC-4.9 RBC-4.88 Hgb-13.9 Hct-41.9 MCV-86 MCH-28.5 MCHC-33.2 RDW-12.9 RDWSD-40.0 Plt ___ ___ 05:15AM BLOOD Glucose-78 UreaN-11 Creat-1.2 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-11 ___ 05:15AM BLOOD ALT-22 AST-14 AlkPhos-105 TotBili-0.___ man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of pancreatitis, presenting with significant abdominal pain and admitted for chronic pancreatitis flare. # Recurrent acute on Chronic Pancreatitis flare: Unknown etiology of pancreatitis. Recent EUS showed evidence of acute and chronic pancreatitis, thought to be possibly autoimmune, though IgG levels were WNL. He is followed by Dr. ___ referred him recently to the pain management clinic where he was initiated on topiramate and amitryptyline. On this admission, CT a/p obtained with findings consistent for acute pancreatitis without complications or other intraabdominal pathology. He briefly required dilaudid PCA for effective analgesia. Otherwise treated with IVF and bowel rest. Ultimately able to advance diet to regular with resumption of pancreatic enzymes. Seen by pain team with plans to expedite follow up for evaluation to receive celiac plexus block. In addition to ongoing follow up with Dr. ___ his pain doctor, recommend ongoing outpatient therapy for stress management. # GERD: - Continued omeprazole 40 mg daily > 30 mins spent on coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 4. Topiramate (Topamax) 50 mg PO DAILY 5. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain Discharge Medications: 1. Amitriptyline 10 mg PO QHS 2. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain 3. Pantoprazole 40 mg PO Q24H 4. Topiramate (Topamax) 50 mg PO DAILY 5. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: # acute on chronic pancreatitis: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted with a flare of your pancreatitis requiring IV pain medications, hydration, and bowel rest. Your symptoms have improved and it is now safe for you to be discharged. Continue to take all other medications as prescribed and make sure you follow up with all appointments as detailed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "K8590", "K861", "K219", "R079", "E669", "Z6829" ]
Allergies: Compazine / Gadolinium-Containing Contrast Media Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of pancreatitis, presenting with significant abdominal pain and admitted for chronic pancreatitis flare. He endorses two weeks of abdominal pain, typically relieved by nighttime hydrocodone. He presented to his local ER in [MASKED] twice over the past two weeks, treated with IV nausea and pain medications, and subsequently discharged. He presented to [MASKED] today because his pain has worsened over the past few days and he has run out of home PO opiates. He endorses RUQ pain, epigastric pain, nausea, and vomiting, typical of his pancreatitis. Chart review shows he had cholecystectomy [MASKED] c/b bile leak s/p stent placement that was removed a month later. After this he developed recurrent RUQ pain and was hospitalized at [MASKED] multiple times for acute pancreatitis (one time confirmed by CT A/P, other time lipase >6000). Extensive workup including ex lap [MASKED] to assess surgical site unrevealing. No known etiology of his pancreatitis. EUS [MASKED] showed acute and chronic pancreatitis possibly autoimmune though MRCP showed no evidence of autoimmune pancreatitis and IgG levels normal. In the ED, initial VS were 97.2 67 127/93 16 99% RA. Labs notable for normal CBC, normal BMP, normal LFTS, and normal lipase. The patient received IV LR, IV Zofran x 2, IV dilaudid .25 x 1, .5 x 1, and 1 mg x 1. He was seen by GI who recommended IV fluids, IV Zofran, and IV pain control and admission to [MASKED] [MASKED]. Upon arrival to the floor, the patient tells the story as follows. He reports a two week worsening of his pain, nausea, and vomiting. The vomiting is not typically of his pancreatitis flares. He presented to [MASKED] and was given a prescription for hydrocodone-acetaminophen, which he has since run out of. He ate breakfast yesterday, but reports a decrease in appetite. He denies fevers, but endorses chills. He reports that his pain has decreased to a [MASKED] but that he still has shooting intermittent pains. He endorses some radiation to his chest which is typical for him and denies shortness of breath. He has gained weight since his last discharge. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Chronic GERD Tubular adenoma of colon [MASKED] GERD [MASKED] Pancreatitis [MASKED] Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: [MASKED]: ERCP stent removal ERCP duct stent placement [MASKED] CCY [MASKED] ERCP to remove duct calculi [MASKED] Elbow arthrosopy/surgery [MASKED] reattached tendon Orthopedic surgery [MASKED] - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries [MASKED] and [MASKED] Social History: [MASKED] Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had [MASKED] disease. MGM had heart disease and died at age [MASKED]. PGM had a malignant tumor breast and DM. She died at age [MASKED]. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Mucous membranes dry CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, tender to palpation in the RUQ and epigastric area, no rebound or guarding MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs EXT: no edema SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect The patient was examined on day of discharge. Pertinent Results: ADMISSION/SIGNIFICANT LABS: ======================== [MASKED] 08:25PM BLOOD WBC-9.2 RBC-5.24 Hgb-15.0 Hct-45.0 MCV-86 MCH-28.6 MCHC-33.3 RDW-13.2 RDWSD-40.5 Plt [MASKED] [MASKED] 08:25PM BLOOD Glucose-91 UreaN-16 Creat-1.0 Na-142 K-4.0 Cl-105 HCO3-22 AnGap-15 [MASKED] 08:25PM BLOOD ALT-25 AST-18 AlkPhos-114 TotBili-0.4 MICRO: ===== none IMAGING/OTHER STUDIES: ==================== CT a/p [MASKED]. Trace peripancreatic stranding and indistinctness of the pancreatic neck and head may suggest mild acute pancreatitis. 2. No evidence of fluid collection, vascular injury, or necrosis. 3. No other acute process in the abdomen pelvis. Normal appendix. LABS ON DISCHARGE: ================= [MASKED] 05:15AM BLOOD WBC-4.9 RBC-4.88 Hgb-13.9 Hct-41.9 MCV-86 MCH-28.5 MCHC-33.2 RDW-12.9 RDWSD-40.0 Plt [MASKED] [MASKED] 05:15AM BLOOD Glucose-78 UreaN-11 Creat-1.2 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-11 [MASKED] 05:15AM BLOOD ALT-22 AST-14 AlkPhos-105 TotBili-0.[MASKED] man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of pancreatitis, presenting with significant abdominal pain and admitted for chronic pancreatitis flare. # Recurrent acute on Chronic Pancreatitis flare: Unknown etiology of pancreatitis. Recent EUS showed evidence of acute and chronic pancreatitis, thought to be possibly autoimmune, though IgG levels were WNL. He is followed by Dr. [MASKED] referred him recently to the pain management clinic where he was initiated on topiramate and amitryptyline. On this admission, CT a/p obtained with findings consistent for acute pancreatitis without complications or other intraabdominal pathology. He briefly required dilaudid PCA for effective analgesia. Otherwise treated with IVF and bowel rest. Ultimately able to advance diet to regular with resumption of pancreatic enzymes. Seen by pain team with plans to expedite follow up for evaluation to receive celiac plexus block. In addition to ongoing follow up with Dr. [MASKED] his pain doctor, recommend ongoing outpatient therapy for stress management. # GERD: - Continued omeprazole 40 mg daily > 30 mins spent on coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 4. Topiramate (Topamax) 50 mg PO DAILY 5. HYDROcodone-acetaminophen [MASKED] mg oral Q6H:PRN pain Discharge Medications: 1. Amitriptyline 10 mg PO QHS 2. HYDROcodone-acetaminophen [MASKED] mg oral Q6H:PRN pain 3. Pantoprazole 40 mg PO Q24H 4. Topiramate (Topamax) 50 mg PO DAILY 5. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: # acute on chronic pancreatitis: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege to care for you at the [MASKED] [MASKED]. You were admitted with a flare of your pancreatitis requiring IV pain medications, hydration, and bowel rest. Your symptoms have improved and it is now safe for you to be discharged. Continue to take all other medications as prescribed and make sure you follow up with all appointments as detailed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219", "E669" ]
[ "K8590: Acute pancreatitis without necrosis or infection, unspecified", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "R079: Chest pain, unspecified", "E669: Obesity, unspecified", "Z6829: Body mass index [BMI] 29.0-29.9, adult" ]
10,058,750
23,135,802
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / Gadolinium-Containing Contrast Media Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EUS (___) History of Present Illness: HPI(4): Mr. ___ is a ___ male with h/o RUQ found to have a CBD stone s/p ERCP ___ followed by CCY ___ c/b bile leak then s/p repeat ERCP with stent placement on ___. He developed c-diff which improved with vancomycin. He then had the ERCP stent removed on ___. He was noted to have a friable cystic duct which was clipped during the initial procedure. With removal of the stent he then developed abdominal pain and has had RUQ pain along with pain radiating from the epigastrum to his chest since then. He was hospitalized for persistent RUQ pain from ___ during which HIDA, MRCP were performed and reportedly unrevealing. He was trialed on gabapentin and tramadol which were ineffective and titrated off. He underwent colonoscopy on ___ revealing a 2-3 cm semi-sessile polyp, tubular adenoma. ERCP on ___ demonstrated mild duodenitis, cystic duct stump 3 cm long and focally dilated to 6 mm possible containig a portion of the GB neck thought c/w possible cytic duct remnant syndrome versus cystic duct mucocele. The sphincterotomy was extended. There as no evidence of bile leak, scant sludge on ballon sweep. He was then hospitalized ___ for post ERCP pancreatitis. On ___ he had a normal o/p capsule endoscopy. He was again admitted on ___ to ___ or acute pancreatitis with lipase 6000, WBC = 18, ___ = 332 and CTAP suggestive of uncomplicated pancreatitis. The cause of his pancreatitis was not clear and was thought to NOT be secondary to a stone since his LFTs were normal, nor ETOH nor ___. On ___ he had an exploaratory laparoscopy to directly assess the surgical site with no noted abnormalities to suggest a surgical cause of his pain. He was hospitalized again from ___ for acute pancreatitis with lipase > 6000, TB = 0.4, ALK-P = 91 ALT =26, AST =19 and WBC = 10,700. US was unrevealing. He saw Dr. ___ on ___ where it was decided that he should undergo an EUS. He then returned home and was admitted the next day to ___ in ___ with worsening abdominal pain. His pain is not worsened with eating. It is worsened with breathing and moving. It also worsened in the ambulance ride over to ___. He had been able to eat a low fat diet. In the ED his labs were unremarkable including normal LFTs, lipase and WBC count. He was afebrile. KUB. He was on dilaudid 1 mg q 2 hours receiving 12 mg IV of dilaudid in 24 hours with his pain improving to ___. Ketamine was initiated on ___ and was discontinued because of sedation on ___. He received IV Zofran and Ativan prn for nausea. He was transferred to ___ for EUS as recommended by Dr. ___. Currently his pain is poorly controlled up to ___. We discuss how to determine the cause of the pain and pain management. Wrt the cause he understands that Dr. ___ has recommended EUS. Wrt pain management, he does not exist in ___ or ___. We agree to 1.5 mg IV dilaudid q 1 hour for 3 doses max while PCA is started. He accepts this plan. He had not had a BM for 4 days or so but this is normal for him when he is admitted to the hospital. He declines a bowel regimen. He has lost unintentionally lost 40 lbs since his surgery in ___. He has a 10 month old son and these frequent hospitalizations have meant that he has missed out on a lot of time with him. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL HISTORY: ==================== Chronic GERD Tubular adenoma of colon ___ GERD ___ Pancreatitis ___ Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: ___: ERCP stent removal ERCP duct stent placement ___ CCY ___ ERCP to remove duct calculi ___ Elbow arthrosopy/surgery ___ reattached tendon Orthopedic surgery ___ - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries ___ and ___ Social History: ___ Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had ___ disease. MGM had heart disease and died at age ___. PGM had a malignant tumor breast and DM. She died at age ___. Physical Exam: ADMISSION: ========== VITALS: ___ Temp: 98.0 PO BP: 116/76 HR: 65 RR: 16 O2 sat: 98% 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 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, + tenderness in the epigastric, RUQ mildly tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE: ============ GENERAL: Man lying in hospital bed, no apparent acute distress EYES: PERRL, anicteric sclerae ENT: OP clear CV: RRR, nl S1, S2, no M/R/G, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: Hypoactive BS, soft, TTP diffusely but mostly in RUQ and epigastrium, ND, +voluntary guarding GU: No suprapubic fullness or tenderness to palpation SKIN: No rashes or ulcerations noted MSK: Lower ext warm without edema NEURO: Alert. Oriented to person/place/time/situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, asterixis, or other involuntary movements observed. PSYCH: Pleasant, appropriate affect Pertinent Results: ADMISSION: ========== ___ 06:59AM BLOOD WBC-4.6 RBC-5.23 Hgb-15.0 Hct-43.6 MCV-83 MCH-28.7 MCHC-34.4 RDW-13.9 RDWSD-42.2 Plt ___ ___ 06:59AM BLOOD Glucose-74 UreaN-9 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-23 AnGap-13 ___ 06:59AM BLOOD ALT-14 AST-13 AlkPhos-96 Amylase-49 TotBili-1.1 ___ 06:59AM BLOOD Lipase-35 ___ 06:59AM BLOOD cTropnT-<0.01 ___ 06:59AM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.3 Mg-1.7 ___ 06:59AM BLOOD Triglyc-175* DISCHARGE: ========== ___ 05:34AM BLOOD WBC-6.1 RBC-4.73 Hgb-13.6* Hct-38.8* MCV-82 MCH-28.8 MCHC-35.1 RDW-13.8 RDWSD-41.1 Plt ___ ___ 05:34AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-142 K-3.6 Cl-106 HCO3-24 AnGap-12 ___ 05:34AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 ___ 07:05AM BLOOD IGG SUBCLASSES 1,2,3,4- within normal for all Other notable: LFTs WNL Albumin 4.5 Lipase 35 Trop <0.01 Trig 175 IgG subclasses: pending ___ labs: ___ --------- 137|103|5/ 4.0| ___ Lipase = 75 Ca = 9 ___: --------- Lipase = 30 Amylase = 45 Lipase ___ = 204 Lead = 2 with normal < 5 ___ Lipase = 551 ___ Lipase = 79 Immunoglobulin G subclass 13 ( ___ HgbA1C = 5.8 ___ ESR = 15 Nml < 15 RF = 10.6; Nml < 14.0 Trig = 290 CEA = 1.6 ___ = 0.1 Nml: < 1.0 IMAGING: ======== EUS (___): Successful upper EUS evaluation as described above, with evidence of chronic pancreatitis seen throughout the pancreatic parenchyma with ___ combing, and hyperechoic strands. In the pancreatic body, the parenchyma was hypoechoic, suggestive of acute pancreatitis vs autoimmune pancreatitis. Cystic duct with area of shadowing, which could represent air or surgical clips. EKG (___): NSR at 63 bpm, nl axis, PR 140, QRS 104, QTC 413, upsloping sub-MM STE V2-V4 (no prior for comparison) KUB (OSH): Normal gas pattern seen in small and large bowel loops. There clips in the RUQ from a CCY likely. No other acute findings are noted. No pathological calcifications. Lung bases are grossly clear. Brief Hospital Course: ___ man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of acute pancreatitis of unclear etiology and acute on chronic abdominal pain presenting as transfer from ___ for further w/u of abdominal pain, found to have likely acute on chronic pancreatitis on ___ of unclear etiology. # Acute on chronic pancreatitis: # Choledocholithiasis s/p CCY c/b bile leak: Developed RUQ abdominal pain ___, for which he was initially treated at ___. Underwent ERCP with removal of CBD stone, followed by CCY ___ c/b bile leak for which a stent was placed ___. Course was complicated by C.diff. Stent was subsequently removed ___, after which he developed recurrent RUQ pain for which he has been hospitalized at ___ multiple times for acute pancreatitis ___/P showed uncomplicated pancreatitis, ___ with lipase >6000). Extensive w/u has been largely unrevealing. HIDA and MRCP ___ were reportedly nl. ERCP ___ demonstrated mild duodenitis, cystic duct stump 3 cm long and focally dilated to 6 mm possibly containing a portion of the GB neck thought c/w possible cystic duct remnant syndrome versus cystic duct mucocele without e/o bile leak. Capsule endoscopy ___ nl. Multiple ultrasounds without e/o stones. Ex laparoscopy to directly assess the CCY surgical site ___ found no abnormalities to suggest a surgical cause of his pain. ___ not markedly elevated, no significant ETOH use, IgG previously nl, ___ nl. He saw Dr. ___ at ___ on ___, at which time plan was made for EUS to evaluate for chronic pancreatitis or occult lesion. Prior to that study he re-presented to ___ with recurrent abdominal pain in the setting of nl lipase. No imaging performed. He was transferred to ___ for further w/u. EUS ___ shows evidence of both acute and chronic pancreatitis, possibly autoimmune. MCRP (with premedication due to allergy to gadolinium) was done which didn't show evidence of autoimmune pancreatitis. And IgG subclasses also all normal. He was gradually able to transition off the PCA, onto pregabalin, onto pantoprazole, and to a regular diet with pancrelipase enzymes with meals. ================== Plan at discharge: ================== - replace home famotidine with pantoprazole 40mg daily - continue pregabalin 100mg BID - continue oral hydromorphone 2mg PRN breakthrough pain - continue pancrelipase enzymes (3 caps) with each meal - advanced endoscopy will set up ___ with the patient in clinic - patient instructed to set up PCP ___ appointment in ___ days The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hyoscyamine 0.375 mg PO Q8H PRN pain 2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 3. Famotidine 80 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. Pancrelipase 5000 3 CAP PO TID W/MEALS RX *lipase-protease-amylase [Zenpep] 5,000 unit-17,000 unit-24,000 unit 3 tab-cap by mouth three times a day before meals Disp #*270 Capsule Refills:*1 3. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Polyethylene Glycol 17 g PO DAILY 5. Pregabalin 100 mg PO BID RX *pregabalin [Lyrica] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 6. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with abdominal pain. An EUS procedure was performed, which showed evidence of both acute and chronic pancreatitis of unclear etiology. You were treated with intravenous fluids, pain medications, and antinausea medications with resolution in your symptoms. A MRCP was done, which showed no evidence of autoimmune pancreatitis. Lab tests done to evaluate for this were also negative. You are being discharged on pregabalin (Lyrica) as well as oral hydromorphone (Dilaudid) for if you need it. You are also being discharged on pancrelipase enzymes to have with meals. Please contact your primary care doctor to set up a post-discharge ___ appointment ideally in the next ___ days. And gastroenterology here will be contacting you to set up a ___ appointment. With best wishes, ___ medicine Followup Instructions: ___
[ "K8590", "K861", "K219", "Z85038", "K8050", "R634" ]
Allergies: Compazine / Gadolinium-Containing Contrast Media Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EUS ([MASKED]) History of Present Illness: HPI(4): Mr. [MASKED] is a [MASKED] male with h/o RUQ found to have a CBD stone s/p ERCP [MASKED] followed by CCY [MASKED] c/b bile leak then s/p repeat ERCP with stent placement on [MASKED]. He developed c-diff which improved with vancomycin. He then had the ERCP stent removed on [MASKED]. He was noted to have a friable cystic duct which was clipped during the initial procedure. With removal of the stent he then developed abdominal pain and has had RUQ pain along with pain radiating from the epigastrum to his chest since then. He was hospitalized for persistent RUQ pain from [MASKED] during which HIDA, MRCP were performed and reportedly unrevealing. He was trialed on gabapentin and tramadol which were ineffective and titrated off. He underwent colonoscopy on [MASKED] revealing a 2-3 cm semi-sessile polyp, tubular adenoma. ERCP on [MASKED] demonstrated mild duodenitis, cystic duct stump 3 cm long and focally dilated to 6 mm possible containig a portion of the GB neck thought c/w possible cytic duct remnant syndrome versus cystic duct mucocele. The sphincterotomy was extended. There as no evidence of bile leak, scant sludge on ballon sweep. He was then hospitalized [MASKED] for post ERCP pancreatitis. On [MASKED] he had a normal o/p capsule endoscopy. He was again admitted on [MASKED] to [MASKED] or acute pancreatitis with lipase 6000, WBC = 18, [MASKED] = 332 and CTAP suggestive of uncomplicated pancreatitis. The cause of his pancreatitis was not clear and was thought to NOT be secondary to a stone since his LFTs were normal, nor ETOH nor [MASKED]. On [MASKED] he had an exploaratory laparoscopy to directly assess the surgical site with no noted abnormalities to suggest a surgical cause of his pain. He was hospitalized again from [MASKED] for acute pancreatitis with lipase > 6000, TB = 0.4, ALK-P = 91 ALT =26, AST =19 and WBC = 10,700. US was unrevealing. He saw Dr. [MASKED] on [MASKED] where it was decided that he should undergo an EUS. He then returned home and was admitted the next day to [MASKED] in [MASKED] with worsening abdominal pain. His pain is not worsened with eating. It is worsened with breathing and moving. It also worsened in the ambulance ride over to [MASKED]. He had been able to eat a low fat diet. In the ED his labs were unremarkable including normal LFTs, lipase and WBC count. He was afebrile. KUB. He was on dilaudid 1 mg q 2 hours receiving 12 mg IV of dilaudid in 24 hours with his pain improving to [MASKED]. Ketamine was initiated on [MASKED] and was discontinued because of sedation on [MASKED]. He received IV Zofran and Ativan prn for nausea. He was transferred to [MASKED] for EUS as recommended by Dr. [MASKED]. Currently his pain is poorly controlled up to [MASKED]. We discuss how to determine the cause of the pain and pain management. Wrt the cause he understands that Dr. [MASKED] has recommended EUS. Wrt pain management, he does not exist in [MASKED] or [MASKED]. We agree to 1.5 mg IV dilaudid q 1 hour for 3 doses max while PCA is started. He accepts this plan. He had not had a BM for 4 days or so but this is normal for him when he is admitted to the hospital. He declines a bowel regimen. He has lost unintentionally lost 40 lbs since his surgery in [MASKED]. He has a 10 month old son and these frequent hospitalizations have meant that he has missed out on a lot of time with him. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL HISTORY: ==================== Chronic GERD Tubular adenoma of colon [MASKED] GERD [MASKED] Pancreatitis [MASKED] Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: [MASKED]: ERCP stent removal ERCP duct stent placement [MASKED] CCY [MASKED] ERCP to remove duct calculi [MASKED] Elbow arthrosopy/surgery [MASKED] reattached tendon Orthopedic surgery [MASKED] - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries [MASKED] and [MASKED] Social History: [MASKED] Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had [MASKED] disease. MGM had heart disease and died at age [MASKED]. PGM had a malignant tumor breast and DM. She died at age [MASKED]. Physical Exam: ADMISSION: ========== VITALS: [MASKED] Temp: 98.0 PO BP: 116/76 HR: 65 RR: 16 O2 sat: 98% 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 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, + tenderness in the epigastric, RUQ mildly tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE: ============ GENERAL: Man lying in hospital bed, no apparent acute distress EYES: PERRL, anicteric sclerae ENT: OP clear CV: RRR, nl S1, S2, no M/R/G, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: Hypoactive BS, soft, TTP diffusely but mostly in RUQ and epigastrium, ND, +voluntary guarding GU: No suprapubic fullness or tenderness to palpation SKIN: No rashes or ulcerations noted MSK: Lower ext warm without edema NEURO: Alert. Oriented to person/place/time/situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, asterixis, or other involuntary movements observed. PSYCH: Pleasant, appropriate affect Pertinent Results: ADMISSION: ========== [MASKED] 06:59AM BLOOD WBC-4.6 RBC-5.23 Hgb-15.0 Hct-43.6 MCV-83 MCH-28.7 MCHC-34.4 RDW-13.9 RDWSD-42.2 Plt [MASKED] [MASKED] 06:59AM BLOOD Glucose-74 UreaN-9 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-23 AnGap-13 [MASKED] 06:59AM BLOOD ALT-14 AST-13 AlkPhos-96 Amylase-49 TotBili-1.1 [MASKED] 06:59AM BLOOD Lipase-35 [MASKED] 06:59AM BLOOD cTropnT-<0.01 [MASKED] 06:59AM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.3 Mg-1.7 [MASKED] 06:59AM BLOOD Triglyc-175* DISCHARGE: ========== [MASKED] 05:34AM BLOOD WBC-6.1 RBC-4.73 Hgb-13.6* Hct-38.8* MCV-82 MCH-28.8 MCHC-35.1 RDW-13.8 RDWSD-41.1 Plt [MASKED] [MASKED] 05:34AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-142 K-3.6 Cl-106 HCO3-24 AnGap-12 [MASKED] 05:34AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 [MASKED] 07:05AM BLOOD IGG SUBCLASSES 1,2,3,4- within normal for all Other notable: LFTs WNL Albumin 4.5 Lipase 35 Trop <0.01 Trig 175 IgG subclasses: pending [MASKED] labs: [MASKED] --------- 137|103|5/ 4.0| [MASKED] Lipase = 75 Ca = 9 [MASKED]: --------- Lipase = 30 Amylase = 45 Lipase [MASKED] = 204 Lead = 2 with normal < 5 [MASKED] Lipase = 551 [MASKED] Lipase = 79 Immunoglobulin G subclass 13 ( [MASKED] HgbA1C = 5.8 [MASKED] ESR = 15 Nml < 15 RF = 10.6; Nml < 14.0 Trig = 290 CEA = 1.6 [MASKED] = 0.1 Nml: < 1.0 IMAGING: ======== EUS ([MASKED]): Successful upper EUS evaluation as described above, with evidence of chronic pancreatitis seen throughout the pancreatic parenchyma with [MASKED] combing, and hyperechoic strands. In the pancreatic body, the parenchyma was hypoechoic, suggestive of acute pancreatitis vs autoimmune pancreatitis. Cystic duct with area of shadowing, which could represent air or surgical clips. EKG ([MASKED]): NSR at 63 bpm, nl axis, PR 140, QRS 104, QTC 413, upsloping sub-MM STE V2-V4 (no prior for comparison) KUB (OSH): Normal gas pattern seen in small and large bowel loops. There clips in the RUQ from a CCY likely. No other acute findings are noted. No pathological calcifications. Lung bases are grossly clear. Brief Hospital Course: [MASKED] man with hx GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C.diff, multiple episodes of acute pancreatitis of unclear etiology and acute on chronic abdominal pain presenting as transfer from [MASKED] for further w/u of abdominal pain, found to have likely acute on chronic pancreatitis on [MASKED] of unclear etiology. # Acute on chronic pancreatitis: # Choledocholithiasis s/p CCY c/b bile leak: Developed RUQ abdominal pain [MASKED], for which he was initially treated at [MASKED]. Underwent ERCP with removal of CBD stone, followed by CCY [MASKED] c/b bile leak for which a stent was placed [MASKED]. Course was complicated by C.diff. Stent was subsequently removed [MASKED], after which he developed recurrent RUQ pain for which he has been hospitalized at [MASKED] multiple times for acute pancreatitis [MASKED]/P showed uncomplicated pancreatitis, [MASKED] with lipase >6000). Extensive w/u has been largely unrevealing. HIDA and MRCP [MASKED] were reportedly nl. ERCP [MASKED] demonstrated mild duodenitis, cystic duct stump 3 cm long and focally dilated to 6 mm possibly containing a portion of the GB neck thought c/w possible cystic duct remnant syndrome versus cystic duct mucocele without e/o bile leak. Capsule endoscopy [MASKED] nl. Multiple ultrasounds without e/o stones. Ex laparoscopy to directly assess the CCY surgical site [MASKED] found no abnormalities to suggest a surgical cause of his pain. [MASKED] not markedly elevated, no significant ETOH use, IgG previously nl, [MASKED] nl. He saw Dr. [MASKED] at [MASKED] on [MASKED], at which time plan was made for EUS to evaluate for chronic pancreatitis or occult lesion. Prior to that study he re-presented to [MASKED] with recurrent abdominal pain in the setting of nl lipase. No imaging performed. He was transferred to [MASKED] for further w/u. EUS [MASKED] shows evidence of both acute and chronic pancreatitis, possibly autoimmune. MCRP (with premedication due to allergy to gadolinium) was done which didn't show evidence of autoimmune pancreatitis. And IgG subclasses also all normal. He was gradually able to transition off the PCA, onto pregabalin, onto pantoprazole, and to a regular diet with pancrelipase enzymes with meals. ================== Plan at discharge: ================== - replace home famotidine with pantoprazole 40mg daily - continue pregabalin 100mg BID - continue oral hydromorphone 2mg PRN breakthrough pain - continue pancrelipase enzymes (3 caps) with each meal - advanced endoscopy will set up [MASKED] with the patient in clinic - patient instructed to set up PCP [MASKED] appointment in [MASKED] days The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hyoscyamine 0.375 mg PO Q8H PRN pain 2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe 3. Famotidine 80 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. Pancrelipase 5000 3 CAP PO TID W/MEALS RX *lipase-protease-amylase [Zenpep] 5,000 unit-17,000 unit-24,000 unit 3 tab-cap by mouth three times a day before meals Disp #*270 Capsule Refills:*1 3. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Polyethylene Glycol 17 g PO DAILY 5. Pregabalin 100 mg PO BID RX *pregabalin [Lyrica] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 6. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital with abdominal pain. An EUS procedure was performed, which showed evidence of both acute and chronic pancreatitis of unclear etiology. You were treated with intravenous fluids, pain medications, and antinausea medications with resolution in your symptoms. A MRCP was done, which showed no evidence of autoimmune pancreatitis. Lab tests done to evaluate for this were also negative. You are being discharged on pregabalin (Lyrica) as well as oral hydromorphone (Dilaudid) for if you need it. You are also being discharged on pancrelipase enzymes to have with meals. Please contact your primary care doctor to set up a post-discharge [MASKED] appointment ideally in the next [MASKED] days. And gastroenterology here will be contacting you to set up a [MASKED] appointment. With best wishes, [MASKED] medicine Followup Instructions: [MASKED]
[]
[ "K219" ]
[ "K8590: Acute pancreatitis without necrosis or infection, unspecified", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "Z85038: Personal history of other malignant neoplasm of large intestine", "K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction", "R634: Abnormal weight loss" ]
10,058,750
28,356,091
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / Gadolinium-Containing Contrast Media Attending: ___. Chief Complaint: Progressive, recurrent abdominal pain Major Surgical or Invasive Procedure: Celiac plexus block History of Present Illness: ___ with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, admitted ___ with recurrent abdominal pain presenting with recurrent abdominal pain reminiscent of prior episodes of pancreatitis. Pt describes onset of RUQ pain that radiates to his back starting on ___, progressive despite home medications. He endorses associated anorexia, denies F/C, chest pain, diarrhea, melena, hematochezia. Pain is the same as prior episodes; he notes that evaluation at Dr. ___ prior to presenting to the ED included an abdominal exam that escalated his pain (although is also appropriately understanding of the need for serial abdominal exams). Pt reports that when he left the hospital on ___, he was in ___ pain, RUQ and epigastrium, intermittently sharp and hard, throbbing pain. As it escalates from ___ to ___, it typically migrates from RUQ more towards the epigastrium. He does not add OTC medications during acute episodes. He uses hydrocodone/APAP at home, which is prescribed q6h prn but he only takes at night. He endorses nausea without emesis. He denies diarrhea, constipation. Denies headaches, SOB. He does get chest pain that is actually radiating epigastric pain, radiates up through R chest. He has been followed by pain service as outpatient, and is undergoing evaluation for celiac plexus block. As part of that evaluation, plan was for u/s guided injection into abdominal muscles on ___, to rule out abdominal wall pain. Pt was seen by Dr. ___ on ___. Based on Dr. ___ from that visit, potential etiologies for his chronic pain with intermittent flares include gallstones within remnant gallbladder, postcholecystectomy syndrome. Plan per Dr. ___ note is to review pt's case at Pancreaticobiliary multidisciplinary management conference on ___. In the ___ ED: VS 97.6, 62, 137/86, 99% RA Exam notable for: General: no acute distress HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Clear to auscultation bilaterally with good aeration, no crackles/wheezes Abdominal/GI: Right upper quadrant tenderness to palpation, soft, nondistended Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted Neuro: Sensation intact upper and lower extremities, strength ___ upper and lower, no focal deficits noted, moving all extremities Labs notable for: WBC 6.9, Hb 14.8, Plt 243 Cr 1.0 LFTs WNL Lipase 45 INR 1.0 Imaging: RUQ u/s: 1. No evidence of biliary ductal stone or obstruction. 2. Mild pneumobilia, previously seen on prior CT dated ___. 3. Nonvisualization of the pancreas. Consults: none Received: Dilaudid 0.5 mg IV x2 Zofran 4 mg IV x2 IVF On arrival to the floor, pt reports ___ pain with nausea. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Chronic GERD Tubular adenoma of colon ___ GERD ___ Pancreatitis ___ Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: ___: ERCP stent removal ERCP duct stent placement ___ CCY ___ ERCP to remove duct calculi ___ Elbow arthrosopy/surgery ___ reattached tendon Orthopedic surgery ___ - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries ___ Social History: ___ Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had ___ disease. ___ had heart disease and died at age ___. PGM had a malignant tumor breast and DM. She died at age ___. Physical Exam: GEN: alert and interactive, no acute distress HEENT: anicteric sclera, face mildly flushed. LUNGS: non labored breathing GI: soft, mild tenderness in epigastrium, normal active bowel sounds EXTREMITIES: no edema SKIN: no new rashes, skin warm NEURO: Alert and interactive, speech fluent PSYCH: normal mood and affect Pertinent Results: ___ 04:08PM BLOOD WBC-6.9 RBC-5.09 Hgb-14.8 Hct-44.5 MCV-87 MCH-29.1 MCHC-33.3 RDW-12.9 RDWSD-41.3 Plt ___ ___ 06:10AM BLOOD WBC-6.0 RBC-5.09 Hgb-14.7 Hct-44.2 MCV-87 MCH-28.9 MCHC-33.3 RDW-12.9 RDWSD-40.3 Plt ___ ___ 04:08PM BLOOD Plt ___ ___ 06:10AM BLOOD ___ ___ 03:11PM BLOOD UreaN-19 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-21* AnGap-16 ___ 06:10AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-145 K-4.0 Cl-107 HCO3-25 AnGap-13 ___ 03:11PM BLOOD ALT-21 AST-16 AlkPhos-120 Amylase-80 TotBili-0.3 ___ 06:10AM BLOOD ALT-19 AST-13 AlkPhos-104 TotBili-0.8 ___ 06:18AM BLOOD Triglyc-257* HDL-26* CHOL/HD-5.7 LDLcalc-71 ___ 06:18AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Cholest-148 MRCP w/ secretin: 1. Findings suggestive of chronic pancreatitis with decreased normal intrinsic T1 hyperintensity of the pancreas, 3 mm dilated side branch in the pancreatic body, and decreased compliance of the pancreatic duct post secretin administration. 2. No findings to suggest main pancreatic duct stricturing or findings to suggest papillary stenosis/pancreatic duct orifice stenosis post secretin administration. 3. No evidence of acute pancreatitis, pancreatic necrosis or peripancreatic collection. 4. Pancreatic fluid is secreted into the second portion of the duodenum after secretin administration, with evaluation of passage of this fluid past the genu limited by pre-existing fluid within small bowel loops which overlap the duodenum. 5. Mild splenomegaly and trace bilateral pleural effusions. Brief Hospital Course: ___ with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, presenting with acute on chronic pain in the setting of chronic pancreatitis # Acute on chronic RUQ/epigastric pain # Chronic pancreatitis # PTSD: Previous EUS and now MRCP with signs of chronic pancreatitis, though his symptoms are such that chronic pancreatitis would not make since as a sole etiology. Other possible contributions include postcholecystectomy pain syndrome and visceral hyperalgesia. A history of trauma is likely also impacting his current experience and his interpretation of pain. Opioid tolerance and hyperalgesia may also be playing a roll. - Weaned opioids to hydromorphone PO 2 mg q 4 hours as needed - ___ has been following with Dr. ___ - ___ to re-schedule his therapy intake - Genetic testing for chronic pancreatitis (Ambry Genetics) pending - Increased home amitriptyline to 25 mg qHS - Continue home tizanidine, topiramate, and zenpep The ___ was seen and examined on the day of discharge. The total time spent preparing discharge was >30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Topiramate (Topamax) 50 mg PO DAILY 4. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain 5. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 6. Tizanidine 2 mg PO QHS:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*42 Tablet Refills:*0 3. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #*30 Packet Refills:*1 4. Senna 8.6 mg PO QHS RX *sennosides 8.6 mg 1 tab by mouth once a day Disp #*30 Tablet Refills:*1 5. Amitriptyline 25 mg PO QHS RX *amitriptyline 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 6. Pantoprazole 40 mg PO Q24H 7. Tizanidine 2 mg PO QHS:PRN pain 8. Topiramate (Topamax) 50 mg PO DAILY 9. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic pancreatitis, postcholecystectomy pain syndrome, visceral hyperalgesia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were seen at ___ for abdominal pain. We performed a celiac plexus block and adjusted your medications to help with this. Followup Instructions: ___
[ "R1011", "K861", "R1013", "K915", "K219", "R203", "F4323", "F4310" ]
Allergies: Compazine / Gadolinium-Containing Contrast Media Chief Complaint: Progressive, recurrent abdominal pain Major Surgical or Invasive Procedure: Celiac plexus block History of Present Illness: [MASKED] with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, admitted [MASKED] with recurrent abdominal pain presenting with recurrent abdominal pain reminiscent of prior episodes of pancreatitis. Pt describes onset of RUQ pain that radiates to his back starting on [MASKED], progressive despite home medications. He endorses associated anorexia, denies F/C, chest pain, diarrhea, melena, hematochezia. Pain is the same as prior episodes; he notes that evaluation at Dr. [MASKED] prior to presenting to the ED included an abdominal exam that escalated his pain (although is also appropriately understanding of the need for serial abdominal exams). Pt reports that when he left the hospital on [MASKED], he was in [MASKED] pain, RUQ and epigastrium, intermittently sharp and hard, throbbing pain. As it escalates from [MASKED] to [MASKED], it typically migrates from RUQ more towards the epigastrium. He does not add OTC medications during acute episodes. He uses hydrocodone/APAP at home, which is prescribed q6h prn but he only takes at night. He endorses nausea without emesis. He denies diarrhea, constipation. Denies headaches, SOB. He does get chest pain that is actually radiating epigastric pain, radiates up through R chest. He has been followed by pain service as outpatient, and is undergoing evaluation for celiac plexus block. As part of that evaluation, plan was for u/s guided injection into abdominal muscles on [MASKED], to rule out abdominal wall pain. Pt was seen by Dr. [MASKED] on [MASKED]. Based on Dr. [MASKED] from that visit, potential etiologies for his chronic pain with intermittent flares include gallstones within remnant gallbladder, postcholecystectomy syndrome. Plan per Dr. [MASKED] note is to review pt's case at Pancreaticobiliary multidisciplinary management conference on [MASKED]. In the [MASKED] ED: VS 97.6, 62, 137/86, 99% RA Exam notable for: General: no acute distress HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Clear to auscultation bilaterally with good aeration, no crackles/wheezes Abdominal/GI: Right upper quadrant tenderness to palpation, soft, nondistended Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted Neuro: Sensation intact upper and lower extremities, strength [MASKED] upper and lower, no focal deficits noted, moving all extremities Labs notable for: WBC 6.9, Hb 14.8, Plt 243 Cr 1.0 LFTs WNL Lipase 45 INR 1.0 Imaging: RUQ u/s: 1. No evidence of biliary ductal stone or obstruction. 2. Mild pneumobilia, previously seen on prior CT dated [MASKED]. 3. Nonvisualization of the pancreas. Consults: none Received: Dilaudid 0.5 mg IV x2 Zofran 4 mg IV x2 IVF On arrival to the floor, pt reports [MASKED] pain with nausea. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Chronic GERD Tubular adenoma of colon [MASKED] GERD [MASKED] Pancreatitis [MASKED] Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: [MASKED]: ERCP stent removal ERCP duct stent placement [MASKED] CCY [MASKED] ERCP to remove duct calculi [MASKED] Elbow arthrosopy/surgery [MASKED] reattached tendon Orthopedic surgery [MASKED] - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries [MASKED] Social History: [MASKED] Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had [MASKED] disease. [MASKED] had heart disease and died at age [MASKED]. PGM had a malignant tumor breast and DM. She died at age [MASKED]. Physical Exam: GEN: alert and interactive, no acute distress HEENT: anicteric sclera, face mildly flushed. LUNGS: non labored breathing GI: soft, mild tenderness in epigastrium, normal active bowel sounds EXTREMITIES: no edema SKIN: no new rashes, skin warm NEURO: Alert and interactive, speech fluent PSYCH: normal mood and affect Pertinent Results: [MASKED] 04:08PM BLOOD WBC-6.9 RBC-5.09 Hgb-14.8 Hct-44.5 MCV-87 MCH-29.1 MCHC-33.3 RDW-12.9 RDWSD-41.3 Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-6.0 RBC-5.09 Hgb-14.7 Hct-44.2 MCV-87 MCH-28.9 MCHC-33.3 RDW-12.9 RDWSD-40.3 Plt [MASKED] [MASKED] 04:08PM BLOOD Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] [MASKED] 03:11PM BLOOD UreaN-19 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-21* AnGap-16 [MASKED] 06:10AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-145 K-4.0 Cl-107 HCO3-25 AnGap-13 [MASKED] 03:11PM BLOOD ALT-21 AST-16 AlkPhos-120 Amylase-80 TotBili-0.3 [MASKED] 06:10AM BLOOD ALT-19 AST-13 AlkPhos-104 TotBili-0.8 [MASKED] 06:18AM BLOOD Triglyc-257* HDL-26* CHOL/HD-5.7 LDLcalc-71 [MASKED] 06:18AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Cholest-148 MRCP w/ secretin: 1. Findings suggestive of chronic pancreatitis with decreased normal intrinsic T1 hyperintensity of the pancreas, 3 mm dilated side branch in the pancreatic body, and decreased compliance of the pancreatic duct post secretin administration. 2. No findings to suggest main pancreatic duct stricturing or findings to suggest papillary stenosis/pancreatic duct orifice stenosis post secretin administration. 3. No evidence of acute pancreatitis, pancreatic necrosis or peripancreatic collection. 4. Pancreatic fluid is secreted into the second portion of the duodenum after secretin administration, with evaluation of passage of this fluid past the genu limited by pre-existing fluid within small bowel loops which overlap the duodenum. 5. Mild splenomegaly and trace bilateral pleural effusions. Brief Hospital Course: [MASKED] with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, presenting with acute on chronic pain in the setting of chronic pancreatitis # Acute on chronic RUQ/epigastric pain # Chronic pancreatitis # PTSD: Previous EUS and now MRCP with signs of chronic pancreatitis, though his symptoms are such that chronic pancreatitis would not make since as a sole etiology. Other possible contributions include postcholecystectomy pain syndrome and visceral hyperalgesia. A history of trauma is likely also impacting his current experience and his interpretation of pain. Opioid tolerance and hyperalgesia may also be playing a roll. - Weaned opioids to hydromorphone PO 2 mg q 4 hours as needed - [MASKED] has been following with Dr. [MASKED] - [MASKED] to re-schedule his therapy intake - Genetic testing for chronic pancreatitis (Ambry Genetics) pending - Increased home amitriptyline to 25 mg qHS - Continue home tizanidine, topiramate, and zenpep The [MASKED] was seen and examined on the day of discharge. The total time spent preparing discharge was >30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Topiramate (Topamax) 50 mg PO DAILY 4. HYDROcodone-acetaminophen [MASKED] mg oral Q6H:PRN pain 5. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 6. Tizanidine 2 mg PO QHS:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*42 Tablet Refills:*0 3. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #*30 Packet Refills:*1 4. Senna 8.6 mg PO QHS RX *sennosides 8.6 mg 1 tab by mouth once a day Disp #*30 Tablet Refills:*1 5. Amitriptyline 25 mg PO QHS RX *amitriptyline 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 6. Pantoprazole 40 mg PO Q24H 7. Tizanidine 2 mg PO QHS:PRN pain 8. Topiramate (Topamax) 50 mg PO DAILY 9. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic pancreatitis, postcholecystectomy pain syndrome, visceral hyperalgesia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were seen at [MASKED] for abdominal pain. We performed a celiac plexus block and adjusted your medications to help with this. Followup Instructions: [MASKED]
[]
[ "K219" ]
[ "R1011: Right upper quadrant pain", "K861: Other chronic pancreatitis", "R1013: Epigastric pain", "K915: Postcholecystectomy syndrome", "K219: Gastro-esophageal reflux disease without esophagitis", "R203: Hyperesthesia", "F4323: Adjustment disorder with mixed anxiety and depressed mood", "F4310: Post-traumatic stress disorder, unspecified" ]
10,058,750
29,974,709
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / Gadolinium-Containing Contrast Media Attending: ___. Major Surgical or Invasive Procedure: ___ - rectus sheath block (performed by Anesthesia) ___ - endoscopy with ultrasound-guided celiac plexus block (performed by Advanced Endoscopy team) attach Pertinent Results: Admission labs: ================= ___ 01:45AM BLOOD WBC-5.9 RBC-5.05 Hgb-14.6 Hct-43.8 MCV-87 MCH-28.9 MCHC-33.3 RDW-12.9 RDWSD-39.9 Plt ___ ___ 01:45AM BLOOD Neuts-53.6 ___ Monos-11.2 Eos-2.0 Baso-0.5 Im ___ AbsNeut-3.16 AbsLymp-1.92 AbsMono-0.66 AbsEos-0.12 AbsBaso-0.03 ___ 01:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-141 K-4.0 Cl-101 HCO3-25 AnGap-15 ___ 01:45AM BLOOD ALT-23 AST-18 AlkPhos-101 TotBili-1.8* DirBili-0.3 IndBili-1.5 ___ 01:45AM BLOOD Albumin-4.7 ___ 05:45AM BLOOD Lactate-0.9 . . Discharge labs: ================= N/A. . . Imaging: ========= ___ RUQ u/s: FINDINGS: Limited evaluation due to acoustic shadowing from overlying bowel gas. Within this limitation, LIVER: The right hepatic lobe parenchyma appears within normal limits. The left hepatic lobe is not very well visualized. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 13.3 cm KIDNEYS: Limited views of the right kidney shows no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Pancreas and left hepatic lobe are not visualized due poor acoustic shadowing. 2. No biliary ductal dilatation in the right hepatic lobe. 3. Patent main portal vein. ___ Endoscopic ultrasound w/ celiac plexus block: see report for details Micro: ======= *Patient had bout of 5 loose stools on ___, which resolved without further intervention and did not recur. Stool sample was sent and infectious studies have been negative thus far, with only the giardia/cryptospora stool DFA pending, for which we have very low ongoing suspicion. ___ 05:13PM STOOL CDIFPCR-NEG ___ 5:13 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: No E. coli O157:H7 found. Cryptosporidium/Giardia (DFA) (Pending): Brief Hospital Course: Mr. ___ presented with acute worsening of chronic right upper quadrant ___ with epigastric ___. VS were normal and stable on presentation. Labs were unremarkable and remained stable. He was treated with oral ___ medications and his ___ remained stable. He was evaluated by the Anesthesia ___ Service, with whom he has previously followed up in clinic, and they recommended celiac plexus block. He underwent a rectus sheath (abdominal wall) injection on ___, performed by the Anesthesia team, which did not significantly improve the ___. The Advanced GI Endoscopy team performed an endoscopy with ultrasound-guided celiac plexus block on ___, which was successful. He was reporting ___ abdominal discomfort ("but not really ___ on the day of discharge following breakfast, a substantial improvement from the ___ ___ he was experiencing prior to the celiac plexus block. He was tolerating a regular diet and oral medications throughout his hospital course as well as on the day of discharge. Of note, he consistently refused heparin SC for VTE ppx, as well as a bowel regimen to prevent and treat opioid-induced constipation (which he experienced), despite counseling, during this hospitalization. He was not provided with any new prescriptions for opioid ___ medications upon discharge. . . . Time in care: >30 minutes in discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Tizanidine 2 mg PO QHS:PRN ___ 4. Topiramate (Topamax) 50 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H 6. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 7. Senna 8.6 mg PO QHS 8. Polyethylene Glycol 17 g PO DAILY 9. HYDROmorphone (Dilaudid) ___ mg PO Q4H Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amitriptyline 25 mg PO QHS 3. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN ___ - Severe 4. Pantoprazole 40 mg PO Q24H 5. Polyethylene Glycol 17 g PO DAILY Hold for > 2 BMs in past 24 hours. 6. Senna 8.6 mg PO QHS Hold if > 2 BMs in past 24 hours. 7. Tizanidine 2 mg PO QHS:PRN ___ Do not drive or operate heavy machinery within 12 hours of taking this medication. 8. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Acute worsening of chronic RUQ & epigastric ___. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You presented to the hospital with worsening ___ in your right upper abdomen and epigastric region. You were evaluated by the Anesthesia ___ specialists, who felt that pursuing a repeat celiac plexus nerve block was a reasonable next step to get your ___ under better control, but unfortunately that procedure would not be available until after the holiday weekend. You underwent a rectus sheath (abdominal wall) injection on ___, performed by the anesthesia team, which did not significantly improve the ___. Yesterday, on ___, you underwent an endoscopy with ultrasound-guided celiac plexus block, performed by the Advanced GI-Endoscopy team. You were able to tolerate an regular diet and oral ___ medications, so you are being discharged home today and we recommend that you contact Dr. ___ office to schedule a follow-up appointment. Please also plan to follow-up with Dr. ___ in the ___ GI clinic at your next scheduled appointment to continue the ongoing evaluation for your abdominal ___ and chronic pancreatitis. We wish you the best. Sincerely, Your ___ Medicine Team Followup Instructions: ___
[ "R1013", "K861", "K219", "G8929", "R197", "K5903", "T402X5A", "Y929" ]
Allergies: Compazine / Gadolinium-Containing Contrast Media Major Surgical or Invasive Procedure: [MASKED] - rectus sheath block (performed by Anesthesia) [MASKED] - endoscopy with ultrasound-guided celiac plexus block (performed by Advanced Endoscopy team) attach Pertinent Results: Admission labs: ================= [MASKED] 01:45AM BLOOD WBC-5.9 RBC-5.05 Hgb-14.6 Hct-43.8 MCV-87 MCH-28.9 MCHC-33.3 RDW-12.9 RDWSD-39.9 Plt [MASKED] [MASKED] 01:45AM BLOOD Neuts-53.6 [MASKED] Monos-11.2 Eos-2.0 Baso-0.5 Im [MASKED] AbsNeut-3.16 AbsLymp-1.92 AbsMono-0.66 AbsEos-0.12 AbsBaso-0.03 [MASKED] 01:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-141 K-4.0 Cl-101 HCO3-25 AnGap-15 [MASKED] 01:45AM BLOOD ALT-23 AST-18 AlkPhos-101 TotBili-1.8* DirBili-0.3 IndBili-1.5 [MASKED] 01:45AM BLOOD Albumin-4.7 [MASKED] 05:45AM BLOOD Lactate-0.9 . . Discharge labs: ================= N/A. . . Imaging: ========= [MASKED] RUQ u/s: FINDINGS: Limited evaluation due to acoustic shadowing from overlying bowel gas. Within this limitation, LIVER: The right hepatic lobe parenchyma appears within normal limits. The left hepatic lobe is not very well visualized. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 13.3 cm KIDNEYS: Limited views of the right kidney shows no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Pancreas and left hepatic lobe are not visualized due poor acoustic shadowing. 2. No biliary ductal dilatation in the right hepatic lobe. 3. Patent main portal vein. [MASKED] Endoscopic ultrasound w/ celiac plexus block: see report for details Micro: ======= *Patient had bout of 5 loose stools on [MASKED], which resolved without further intervention and did not recur. Stool sample was sent and infectious studies have been negative thus far, with only the giardia/cryptospora stool DFA pending, for which we have very low ongoing suspicion. [MASKED] 05:13PM STOOL CDIFPCR-NEG [MASKED] 5:13 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final [MASKED]: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [MASKED]: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [MASKED]: No E. coli O157:H7 found. Cryptosporidium/Giardia (DFA) (Pending): Brief Hospital Course: Mr. [MASKED] presented with acute worsening of chronic right upper quadrant [MASKED] with epigastric [MASKED]. VS were normal and stable on presentation. Labs were unremarkable and remained stable. He was treated with oral [MASKED] medications and his [MASKED] remained stable. He was evaluated by the Anesthesia [MASKED] Service, with whom he has previously followed up in clinic, and they recommended celiac plexus block. He underwent a rectus sheath (abdominal wall) injection on [MASKED], performed by the Anesthesia team, which did not significantly improve the [MASKED]. The Advanced GI Endoscopy team performed an endoscopy with ultrasound-guided celiac plexus block on [MASKED], which was successful. He was reporting [MASKED] abdominal discomfort ("but not really [MASKED] on the day of discharge following breakfast, a substantial improvement from the [MASKED] [MASKED] he was experiencing prior to the celiac plexus block. He was tolerating a regular diet and oral medications throughout his hospital course as well as on the day of discharge. Of note, he consistently refused heparin SC for VTE ppx, as well as a bowel regimen to prevent and treat opioid-induced constipation (which he experienced), despite counseling, during this hospitalization. He was not provided with any new prescriptions for opioid [MASKED] medications upon discharge. . . . Time in care: >30 minutes in discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Tizanidine 2 mg PO QHS:PRN [MASKED] 4. Topiramate (Topamax) 50 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H 6. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 7. Senna 8.6 mg PO QHS 8. Polyethylene Glycol 17 g PO DAILY 9. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amitriptyline 25 mg PO QHS 3. HYDROcodone-Acetaminophen (5mg-325mg) [MASKED] TAB PO Q4H:PRN [MASKED] - Severe 4. Pantoprazole 40 mg PO Q24H 5. Polyethylene Glycol 17 g PO DAILY Hold for > 2 BMs in past 24 hours. 6. Senna 8.6 mg PO QHS Hold if > 2 BMs in past 24 hours. 7. Tizanidine 2 mg PO QHS:PRN [MASKED] Do not drive or operate heavy machinery within 12 hours of taking this medication. 8. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Acute worsening of chronic RUQ & epigastric [MASKED]. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You presented to the hospital with worsening [MASKED] in your right upper abdomen and epigastric region. You were evaluated by the Anesthesia [MASKED] specialists, who felt that pursuing a repeat celiac plexus nerve block was a reasonable next step to get your [MASKED] under better control, but unfortunately that procedure would not be available until after the holiday weekend. You underwent a rectus sheath (abdominal wall) injection on [MASKED], performed by the anesthesia team, which did not significantly improve the [MASKED]. Yesterday, on [MASKED], you underwent an endoscopy with ultrasound-guided celiac plexus block, performed by the Advanced GI-Endoscopy team. You were able to tolerate an regular diet and oral [MASKED] medications, so you are being discharged home today and we recommend that you contact Dr. [MASKED] office to schedule a follow-up appointment. Please also plan to follow-up with Dr. [MASKED] in the [MASKED] GI clinic at your next scheduled appointment to continue the ongoing evaluation for your abdominal [MASKED] and chronic pancreatitis. We wish you the best. Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "K219", "G8929", "Y929" ]
[ "R1013: Epigastric pain", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain", "R197: Diarrhea, unspecified", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable" ]
10,058,856
21,320,571
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Aspirin / Duragesic / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Penicillins / Flagyl Attending: ___. Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: ___: Left common femoral artery endarterectomy History of Present Illness: This patient is a ___ woman with a history of progressive left leg ischemia with intermittent rest pain. Last week, she was taken to the angiography suite where she was found to have a left common femoral, high-grade stenosis and a left SFA occlusion. I decided to proceed with left SFA intervention prior to treating inflow disease. We performed the SFA stenting and sent her home for several days and she is now back for her inflow procedure. I am doing this primarily to improve perfusion and maintain stent patency. The procedure and risks were explained to her and her sister. They understood and wished to proceed. Past Medical History: HTN migraines, takes fioricet multiple times a day IBS OA ?seizure disorder GERD depression borderline personality d/o narcotic abuse has port-a-cath for "IVF" for "chronic ileus" per patient Social History: ___ Family History: NC Physical Exam: Vitals: AVSS, see flowsheets GEN: NAD, pleasant, conversant Resp: No increased work of breathing, clear to auscultation bilaterally CV: RRR Abd: Soft, non-tender, non-distended Wound: Left groin incision is clean and intact with minimal serosanguinous drainage. Extremities: Warm, well perfused Pulse exam: R:pfem/pPop/dDP/dPT L:p/p/d/d Pertinent Results: ___ 09:40AM URINE HOURS-RANDOM ___ 09:40AM URINE GR HOLD-HOLD ___ 09:40AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG* ___ 09:40AM URINE RBC-1 WBC-19* BACTERIA-FEW* YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 09:40AM URINE AMORPH-RARE* Brief Hospital Course: ___ is a ___ year-old woman left lower extremity rest pain, recently s/p angio showing L CFA 50% stenosis and L SFA stenosis s/p PTA/stent on ___ who was admitted to the ___ ___ on ___. The patient was taken to the endovascular suite and underwent a left common femoral artery endarterectomy. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization. Post-operatively, she did well without any groin swelling. She did have incisional pain on post-operative day #1, and her pain regimen was titrated accordingly. She was able to tolerate a regular diet, get out of bed and ambulate with assistance of staff for support, void without issues, and pain was controlled on oral medications alone. By POD#2, she was deemed ready for discharge to a ___ rehabilitation facility. She was given the appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. Lisinopril 20 mg PO DAILY 3. Gabapentin 500 mg PO TID 4. DICYCLOMine 20 mg PO BID 5. Propranolol LA 60 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Multivitamins 1 TAB PO DAILY 8. Perphenazine 4 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. FLUoxetine 40 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID Hold for loose or frequent stool. 3. Ondansetron ODT 4 mg SL Q8H:PRN Nausea RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*10 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*10 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation 6. Acetaminophen 650 mg PO Q8H 7. Atorvastatin 80 mg PO QPM 8. Cyanocobalamin 500 mcg PO DAILY 9. DICYCLOMine 20 mg PO BID 10. FLUoxetine 40 mg PO DAILY 11. Gabapentin 500 mg PO TID 12. Lisinopril 20 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. Perphenazine 4 mg PO DAILY 16. Propranolol LA 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for surgery to improve the blood flow to your left leg. You underwent a left CFA endarterectomy. You have recovered well and are now ready for discharge home. Please follow the instructions below regarding your care to ensure a speedy recovery: MEDICATION: • If instructed, take Plavix (Clopidogrel) 75mg once daily for 30 days, then take aspirin daily. • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: • Elevate your leg above the level of your heart with pillows every ___ hours throughout the day and night • Avoid prolonged periods of standing or sitting without your legs elevated • It is normal to feel tired and have a decreased appetite, your appetite will return with time • Drink plenty of fluids and eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • Unless you were told not to bear any weight on operative foot: • You should get up every day, get dressed and walk • You should gradually increase your activity • You may up and down stairs, go outside and/or ride in a car • Increase your activities as you can tolerate- do not do too much right away! • No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit • You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed CALL THE OFFICE FOR: ___ • Redness that extends away from your incision • A sudden increase in pain that is not controlled with pain medication • A sudden change in the ability to move or use your leg or the ability to feel your leg • Temperature greater than 100.5F for 24 hours • Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Thank you for allowing us to participate in your medical care. Sincerely, Your ___ Surgery Team Followup Instructions: ___
[ "I70222", "I10", "I771", "G43909", "K219", "F329", "F17210", "Z8673", "E785" ]
Allergies: Aspirin / Duragesic / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Penicillins / Flagyl Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: [MASKED]: Left common femoral artery endarterectomy History of Present Illness: This patient is a [MASKED] woman with a history of progressive left leg ischemia with intermittent rest pain. Last week, she was taken to the angiography suite where she was found to have a left common femoral, high-grade stenosis and a left SFA occlusion. I decided to proceed with left SFA intervention prior to treating inflow disease. We performed the SFA stenting and sent her home for several days and she is now back for her inflow procedure. I am doing this primarily to improve perfusion and maintain stent patency. The procedure and risks were explained to her and her sister. They understood and wished to proceed. Past Medical History: HTN migraines, takes fioricet multiple times a day IBS OA ?seizure disorder GERD depression borderline personality d/o narcotic abuse has port-a-cath for "IVF" for "chronic ileus" per patient Social History: [MASKED] Family History: NC Physical Exam: Vitals: AVSS, see flowsheets GEN: NAD, pleasant, conversant Resp: No increased work of breathing, clear to auscultation bilaterally CV: RRR Abd: Soft, non-tender, non-distended Wound: Left groin incision is clean and intact with minimal serosanguinous drainage. Extremities: Warm, well perfused Pulse exam: R:pfem/pPop/dDP/dPT L:p/p/d/d Pertinent Results: [MASKED] 09:40AM URINE HOURS-RANDOM [MASKED] 09:40AM URINE GR HOLD-HOLD [MASKED] 09:40AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 09:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG* [MASKED] 09:40AM URINE RBC-1 WBC-19* BACTERIA-FEW* YEAST-NONE EPI-<1 TRANS EPI-<1 [MASKED] 09:40AM URINE AMORPH-RARE* Brief Hospital Course: [MASKED] is a [MASKED] year-old woman left lower extremity rest pain, recently s/p angio showing L CFA 50% stenosis and L SFA stenosis s/p PTA/stent on [MASKED] who was admitted to the [MASKED] [MASKED] on [MASKED]. The patient was taken to the endovascular suite and underwent a left common femoral artery endarterectomy. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization. Post-operatively, she did well without any groin swelling. She did have incisional pain on post-operative day #1, and her pain regimen was titrated accordingly. She was able to tolerate a regular diet, get out of bed and ambulate with assistance of staff for support, void without issues, and pain was controlled on oral medications alone. By POD#2, she was deemed ready for discharge to a [MASKED] rehabilitation facility. She was given the appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. Lisinopril 20 mg PO DAILY 3. Gabapentin 500 mg PO TID 4. DICYCLOMine 20 mg PO BID 5. Propranolol LA 60 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Multivitamins 1 TAB PO DAILY 8. Perphenazine 4 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. FLUoxetine 40 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID Hold for loose or frequent stool. 3. Ondansetron ODT 4 mg SL Q8H:PRN Nausea RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*10 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*10 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation 6. Acetaminophen 650 mg PO Q8H 7. Atorvastatin 80 mg PO QPM 8. Cyanocobalamin 500 mcg PO DAILY 9. DICYCLOMine 20 mg PO BID 10. FLUoxetine 40 mg PO DAILY 11. Gabapentin 500 mg PO TID 12. Lisinopril 20 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. Perphenazine 4 mg PO DAILY 16. Propranolol LA 60 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for surgery to improve the blood flow to your left leg. You underwent a left CFA endarterectomy. You have recovered well and are now ready for discharge home. Please follow the instructions below regarding your care to ensure a speedy recovery: MEDICATION: • If instructed, take Plavix (Clopidogrel) 75mg once daily for 30 days, then take aspirin daily. • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: • Elevate your leg above the level of your heart with pillows every [MASKED] hours throughout the day and night • Avoid prolonged periods of standing or sitting without your legs elevated • It is normal to feel tired and have a decreased appetite, your appetite will return with time • Drink plenty of fluids and eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • Unless you were told not to bear any weight on operative foot: • You should get up every day, get dressed and walk • You should gradually increase your activity • You may up and down stairs, go outside and/or ride in a car • Increase your activities as you can tolerate- do not do too much right away! • No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit • You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed CALL THE OFFICE FOR: [MASKED] • Redness that extends away from your incision • A sudden increase in pain that is not controlled with pain medication • A sudden change in the ability to move or use your leg or the ability to feel your leg • Temperature greater than 100.5F for 24 hours • Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Thank you for allowing us to participate in your medical care. Sincerely, Your [MASKED] Surgery Team Followup Instructions: [MASKED]
[]
[ "I10", "K219", "F329", "F17210", "Z8673", "E785" ]
[ "I70222: Atherosclerosis of native arteries of extremities with rest pain, left leg", "I10: Essential (primary) hypertension", "I771: Stricture of artery", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified" ]
10,058,856
29,328,838
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Duragesic / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Penicillins / Flagyl Attending: ___ Chief Complaint: Left groin pain at incision site for 3 days Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p left common femoral endarterectomy ___ with Dr. ___ with complain of left groin pain at incision site for 3 days, found on OSH CT scan (currently unavailable) to have reported 2 cm collection superficial to CFA. The patient states she has had 3 days of left groin pain that is ___, causing her to go to her PCP ___. Her PCP obtained ___ CT scan which revealed the fluid collection. She came to ___ ED after learning the results. The scans are not currently available due to a tech issue. She reports taking her Plavix as prescribed (scheduled to stop next day after admission). She denies numbness or tingling in either lower extremity, extremities are WWP, and denies CP, SOB, HA, and all other symptoms. Past Medical History: HTN migraines, takes fioricet multiple times a day IBS OA ?seizure disorder GERD depression borderline personality d/o narcotic abuse had port-a-cath for "IVF" for "chronic ileus" per patient Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM ============================= Vitals: T 98.1 / BP 136/83 / HR 64 / RR 18 / O2sat 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: non-labored respirations on RA ABD: Soft, nondistended, focal mild TTP LLQ, no rebound or guarding, normoactive bowel sounds, no palpable masses. Left groin incision well healed Extremities: warm and well-perfused Neuro: A&OX3 DISCHARGE PHYSICAL EXAM ========================= VS: AF 100-140s/70s 50-60s 18 95-97% RA I/O: ___ GENERAL: NAD, resting comfortably, A&O to hospital, year, self HEENT: AT/NC HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: mildly tender in LLQ. +BS. EXTREMITIES: site of L femoral endarterectomy appears c/d/I without tenderness or erythema/ no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII grossly intact except baseline L sided facial droop, moving all extremities with purpose, DOWB intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ==================== ___ 12:15AM BLOOD WBC-21.7* RBC-4.74 Hgb-11.3 Hct-36.4 MCV-77* MCH-23.8* MCHC-31.0* RDW-16.6* RDWSD-45.6 Plt ___ ___ 12:15AM BLOOD Neuts-80.8* Lymphs-9.5* Monos-6.1 Eos-2.4 Baso-0.6 Im ___ AbsNeut-17.50* AbsLymp-2.07 AbsMono-1.33* AbsEos-0.52 AbsBaso-0.14* ___ 12:15AM BLOOD ___ PTT-27.2 ___ ___ 12:15AM BLOOD Glucose-80 UreaN-6 Creat-0.7 Na-138 K-3.2* Cl-98 HCO3-23 AnGap-17 ___ 05:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5* DISCHARGE LABS =================== ___ 05:45AM BLOOD WBC-12.6* RBC-4.06 Hgb-9.6* Hct-31.2* MCV-77* MCH-23.6* MCHC-30.8* RDW-16.7* RDWSD-46.3 Plt ___ ___ 05:45AM BLOOD Glucose-101* UreaN-5* Creat-0.8 Na-136 K-4.2 Cl-101 HCO3-24 AnGap-11 ___ 05:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8 IMAGING =========== CT ABD/PELV ___. Limited examination without IV contrast. 2. No imaging findings to explain left lower quadrant pain. While there is mild thickening of the sigmoid colonic wall and equivocal adjacent fat stranding, this is a fairly similar appearance to the prior CT from ___, and likely related to muscular hypertrophy related to chronic diverticular disease. 3. Small amount of fat stranding in fluid density in the left groin region likely represent sequelae from prior intervention. Please correlate with any prior recent interventions to the left groin. 4. Persistent dilation of the right renal collecting system. LLE U/S A2.4 x 1.2 x 0.8 cm irregular fluid collection with internal debris could represent abscess versus hematoma. Surrounding soft tissue edema favors abscess. Comparison can be made if prior imaging becomes available. Brief Hospital Course: ___ s/p left common femoral endarterectomy ___, who's presenting with 3 days of pain, found to likely have small hematoma at site of recent endarterectomy with leukocytosis to 21 initially concerning for abscess, but found to have possible diverticulitis on CT scan, which improved with antibiotics. # Diverticulitis # Leukocytosis Patient with elevated WBC and LLQ abdominal pain, initially thought ___ abscess at L femoral site per vascular surgery. However CT scan unremarkable for infection at site, but did reveal sigmoid thickening initially concerning for diverticulitis on preliminary read, but then later final read thought this was less likely. UA/cx NGTD, BCx NGTD, CXR unremarkable, no other signs of infection elsewhere. Patient was initially treated with vanco/cipro/flagyl (note that per chart she has a Flagyl allergy but pt denies this and she tolerated flagyl well) which was narrowed to cipro/flagyl only, with improvement in leukocytosis and abdominal pain. She will complete 7 day course of abx (last day ___. Patient was continued on bowel regimen and pain controlled with oxycodone initially 10mg q4h downtitrated to 5mg q4h on discharge. Tolerating solid PO diet on discharge. She should have a colonoscopy ___ weeks after discharge #Peripheral vascular disease s/p left common femoral endarterectomy ___ Patient continued on Plavix and statin. Normally, would transition to ASA 81mg 30 days after vascular procedure; however, patient with aspirin allergy. Recommend continuing Plavix until follow up with vascular in 1 month after discharge. #Abdominal Pain Continued home dicyclomine and Zofran. Treated diverticulitis as above. # HTN Continued home lisinopril and propranolol # history psych disorders Continued home perphenazine 4mg and fluoxetine 40mg # GERD Continued home pantoprazole # Disposition/inability to care for self As per social history, patient had been living with a roommate who was also not very good at self-care but together the two of them compensated for each other. Per her sister and her case manager, since the roommate died the patient has had poor self care due to chronic cognitive weakness, namely not eating, not being able to do ADLs, and at one point getting lost outside in the winter. Was seen by ___ who found she had impaired orientation, memory, safety awareness. Sister had been working on a bed at a facility, and patient was amenable to go there on discharge, so HCP did not need to be invoked. For billing purposes only: >30 minutes spent on patient care and coordination. TRANSITIONAL ISSUES ========================= []Continue ciprofloxacin and flagyl to complete 7 day course of abx (last day ___. []Recommend colonoscopy ___ weeks after discharge []Please titrate off oxycodone as was only started for abdominal pain on admission []Recommend allergy appt as outpatient as has multiple unknown allergies including penicillin, sulfas []Pt with aspirin allergy. She will continue on Plavix until follow up with vascular surgery. She should have duplex of her LLE and follow up with Dr. ___ 1 month after discharge. Please call ___ to receive this followup appointment as it is currently pending. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. DICYCLOMine 20 mg PO BID 4. FLUoxetine 20 mg PO DAILY 5. Gabapentin 200 mg PO TID 6. Lisinopril 20 mg PO DAILY 7. Ondansetron Dose is Unknown PO Frequency is Unknown 8. Pantoprazole 40 mg PO Q24H 9. Perphenazine 4 mg PO ONCE 10. Propranolol LA 60 mg PO DAILY 11. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 12. Cyanocobalamin 500 mcg PO DAILY 13. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO Q8H 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*15 Capsule Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 17.2 mg PO HS 6. Acetaminophen 1000 mg PO TID 7. Ondansetron ODT 4 mg PO Q8H:PRN nausea 8. Atorvastatin 80 mg PO QPM 9. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY 10. Clopidogrel 75 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY 12. DICYCLOMine 20 mg PO BID 13. FLUoxetine 40 mg PO DAILY 14. Gabapentin 500 mg PO TID 15. Lisinopril 20 mg PO DAILY 16. Pantoprazole 40 mg PO Q24H 17. Perphenazine 4 mg PO DAILY 18. Propranolol LA 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Diverticulitis SECONDARY: Hypertension Psychiatric Disorders Peripheral vascular disease s/p Left common femoral endarterectomy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you. Why you were admitted? - You were admitted because you were having abdominal pain. What we did for you? - You were found to have an infection in your bowel can diverticulitis. You were treated with antibiotics with improvement. - The occupational therapist recommended that you go to rehab What should you do when you leave the hospital? - Please continue taking all your medications - Please continue taking your antibiotics (ciprofloxacin & metronidazole) to complete a 7 day course (last day ___. - Please attend your follow up appointments. - You should receive a call from the vascular surgery clinic regarding an appointment with Dr. ___ to be scheduled in 1 month after discharge. If you do not hear back within 3 days please call ___. We wish you the best, Your ___ team Followup Instructions: ___
[ "K5792", "I10", "D72829", "I739", "K219", "G43909", "F329" ]
Allergies: Aspirin / Duragesic / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Penicillins / Flagyl Chief Complaint: Left groin pain at incision site for 3 days Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] s/p left common femoral endarterectomy [MASKED] with Dr. [MASKED] with complain of left groin pain at incision site for 3 days, found on OSH CT scan (currently unavailable) to have reported 2 cm collection superficial to CFA. The patient states she has had 3 days of left groin pain that is [MASKED], causing her to go to her PCP [MASKED]. Her PCP obtained [MASKED] CT scan which revealed the fluid collection. She came to [MASKED] ED after learning the results. The scans are not currently available due to a tech issue. She reports taking her Plavix as prescribed (scheduled to stop next day after admission). She denies numbness or tingling in either lower extremity, extremities are WWP, and denies CP, SOB, HA, and all other symptoms. Past Medical History: HTN migraines, takes fioricet multiple times a day IBS OA ?seizure disorder GERD depression borderline personality d/o narcotic abuse had port-a-cath for "IVF" for "chronic ileus" per patient Social History: [MASKED] Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM ============================= Vitals: T 98.1 / BP 136/83 / HR 64 / RR 18 / O2sat 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: non-labored respirations on RA ABD: Soft, nondistended, focal mild TTP LLQ, no rebound or guarding, normoactive bowel sounds, no palpable masses. Left groin incision well healed Extremities: warm and well-perfused Neuro: A&OX3 DISCHARGE PHYSICAL EXAM ========================= VS: AF 100-140s/70s 50-60s 18 95-97% RA I/O: [MASKED] GENERAL: NAD, resting comfortably, A&O to hospital, year, self HEENT: AT/NC HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: mildly tender in LLQ. +BS. EXTREMITIES: site of L femoral endarterectomy appears c/d/I without tenderness or erythema/ no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII grossly intact except baseline L sided facial droop, moving all extremities with purpose, DOWB intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ==================== [MASKED] 12:15AM BLOOD WBC-21.7* RBC-4.74 Hgb-11.3 Hct-36.4 MCV-77* MCH-23.8* MCHC-31.0* RDW-16.6* RDWSD-45.6 Plt [MASKED] [MASKED] 12:15AM BLOOD Neuts-80.8* Lymphs-9.5* Monos-6.1 Eos-2.4 Baso-0.6 Im [MASKED] AbsNeut-17.50* AbsLymp-2.07 AbsMono-1.33* AbsEos-0.52 AbsBaso-0.14* [MASKED] 12:15AM BLOOD [MASKED] PTT-27.2 [MASKED] [MASKED] 12:15AM BLOOD Glucose-80 UreaN-6 Creat-0.7 Na-138 K-3.2* Cl-98 HCO3-23 AnGap-17 [MASKED] 05:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5* DISCHARGE LABS =================== [MASKED] 05:45AM BLOOD WBC-12.6* RBC-4.06 Hgb-9.6* Hct-31.2* MCV-77* MCH-23.6* MCHC-30.8* RDW-16.7* RDWSD-46.3 Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-101* UreaN-5* Creat-0.8 Na-136 K-4.2 Cl-101 HCO3-24 AnGap-11 [MASKED] 05:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8 IMAGING =========== CT ABD/PELV [MASKED]. Limited examination without IV contrast. 2. No imaging findings to explain left lower quadrant pain. While there is mild thickening of the sigmoid colonic wall and equivocal adjacent fat stranding, this is a fairly similar appearance to the prior CT from [MASKED], and likely related to muscular hypertrophy related to chronic diverticular disease. 3. Small amount of fat stranding in fluid density in the left groin region likely represent sequelae from prior intervention. Please correlate with any prior recent interventions to the left groin. 4. Persistent dilation of the right renal collecting system. LLE U/S A2.4 x 1.2 x 0.8 cm irregular fluid collection with internal debris could represent abscess versus hematoma. Surrounding soft tissue edema favors abscess. Comparison can be made if prior imaging becomes available. Brief Hospital Course: [MASKED] s/p left common femoral endarterectomy [MASKED], who's presenting with 3 days of pain, found to likely have small hematoma at site of recent endarterectomy with leukocytosis to 21 initially concerning for abscess, but found to have possible diverticulitis on CT scan, which improved with antibiotics. # Diverticulitis # Leukocytosis Patient with elevated WBC and LLQ abdominal pain, initially thought [MASKED] abscess at L femoral site per vascular surgery. However CT scan unremarkable for infection at site, but did reveal sigmoid thickening initially concerning for diverticulitis on preliminary read, but then later final read thought this was less likely. UA/cx NGTD, BCx NGTD, CXR unremarkable, no other signs of infection elsewhere. Patient was initially treated with vanco/cipro/flagyl (note that per chart she has a Flagyl allergy but pt denies this and she tolerated flagyl well) which was narrowed to cipro/flagyl only, with improvement in leukocytosis and abdominal pain. She will complete 7 day course of abx (last day [MASKED]. Patient was continued on bowel regimen and pain controlled with oxycodone initially 10mg q4h downtitrated to 5mg q4h on discharge. Tolerating solid PO diet on discharge. She should have a colonoscopy [MASKED] weeks after discharge #Peripheral vascular disease s/p left common femoral endarterectomy [MASKED] Patient continued on Plavix and statin. Normally, would transition to ASA 81mg 30 days after vascular procedure; however, patient with aspirin allergy. Recommend continuing Plavix until follow up with vascular in 1 month after discharge. #Abdominal Pain Continued home dicyclomine and Zofran. Treated diverticulitis as above. # HTN Continued home lisinopril and propranolol # history psych disorders Continued home perphenazine 4mg and fluoxetine 40mg # GERD Continued home pantoprazole # Disposition/inability to care for self As per social history, patient had been living with a roommate who was also not very good at self-care but together the two of them compensated for each other. Per her sister and her case manager, since the roommate died the patient has had poor self care due to chronic cognitive weakness, namely not eating, not being able to do ADLs, and at one point getting lost outside in the winter. Was seen by [MASKED] who found she had impaired orientation, memory, safety awareness. Sister had been working on a bed at a facility, and patient was amenable to go there on discharge, so HCP did not need to be invoked. For billing purposes only: >30 minutes spent on patient care and coordination. TRANSITIONAL ISSUES ========================= []Continue ciprofloxacin and flagyl to complete 7 day course of abx (last day [MASKED]. []Recommend colonoscopy [MASKED] weeks after discharge []Please titrate off oxycodone as was only started for abdominal pain on admission []Recommend allergy appt as outpatient as has multiple unknown allergies including penicillin, sulfas []Pt with aspirin allergy. She will continue on Plavix until follow up with vascular surgery. She should have duplex of her LLE and follow up with Dr. [MASKED] 1 month after discharge. Please call [MASKED] to receive this followup appointment as it is currently pending. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. DICYCLOMine 20 mg PO BID 4. FLUoxetine 20 mg PO DAILY 5. Gabapentin 200 mg PO TID 6. Lisinopril 20 mg PO DAILY 7. Ondansetron Dose is Unknown PO Frequency is Unknown 8. Pantoprazole 40 mg PO Q24H 9. Perphenazine 4 mg PO ONCE 10. Propranolol LA 60 mg PO DAILY 11. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 12. Cyanocobalamin 500 mcg PO DAILY 13. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO Q8H 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*15 Capsule Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 17.2 mg PO HS 6. Acetaminophen 1000 mg PO TID 7. Ondansetron ODT 4 mg PO Q8H:PRN nausea 8. Atorvastatin 80 mg PO QPM 9. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY 10. Clopidogrel 75 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY 12. DICYCLOMine 20 mg PO BID 13. FLUoxetine 40 mg PO DAILY 14. Gabapentin 500 mg PO TID 15. Lisinopril 20 mg PO DAILY 16. Pantoprazole 40 mg PO Q24H 17. Perphenazine 4 mg PO DAILY 18. Propranolol LA 60 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: Diverticulitis SECONDARY: Hypertension Psychiatric Disorders Peripheral vascular disease s/p Left common femoral endarterectomy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you. Why you were admitted? - You were admitted because you were having abdominal pain. What we did for you? - You were found to have an infection in your bowel can diverticulitis. You were treated with antibiotics with improvement. - The occupational therapist recommended that you go to rehab What should you do when you leave the hospital? - Please continue taking all your medications - Please continue taking your antibiotics (ciprofloxacin & metronidazole) to complete a 7 day course (last day [MASKED]. - Please attend your follow up appointments. - You should receive a call from the vascular surgery clinic regarding an appointment with Dr. [MASKED] to be scheduled in 1 month after discharge. If you do not hear back within 3 days please call [MASKED]. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "I10", "K219", "F329" ]
[ "K5792: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding", "I10: Essential (primary) hypertension", "D72829: Elevated white blood cell count, unspecified", "I739: Peripheral vascular disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F329: Major depressive disorder, single episode, unspecified" ]
10,058,868
20,377,504
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Generalized tonic-clonic seizure Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year-old man with history of a prior seizure in ___ (unclear circumstances) and alcohol use who presents with three witnessed events concerning for seizure. The vast majority of the history is provided by the patient's two friends ___ and ___ and records, as the patient is unable to provide much history due to mental status. Per the patient's friends, Mr. ___ was in his usual state of health until approximately 5:30PM this evening. He was watching TV with his mother, when she witnessed him "having a seizure." His mother called the friends to come see him. His friends note that the patient's mother has baseline cognitive/memory issues and is a poor historian; she was unable to give more information about what she saw. By the time the friends arrived approximately 10 minutes later, they note the patient was laying on the couch awake, but "staring glassy eyed", non verbal, and not responding to their questions. He had a small amount of blood visible in his mouth. Several minutes later, they witnessed his right arm extend above his head, turn his head to the right, make gurgling noise in his mouth and clench his teeth tightly. This was followed by shaking of the right arm, lasting "a few minutes." His friends were not sure whether the other three extremities were shaking at this time. They brought him to the floor and thought it was best to try to suppress the movements, so they held down all four extremities tightly. They called EMS. After the event, the patient remained confused as he was before. By the time EMS arrived, the patient had another event. This was characterized by stiffening of all four extremities followed by rapid shaking movements. This was associated with urinary incontinence and tongue biting. He was brought to ___ and received 2mg of IV Ativan and 500cc NS en route. On arrival to ___, the patient was initially noted to be nonverbal but responsive to painful stimuli. He received 1g of IV Keppra, and was transferred to ___ for neurologic evaluation and consideration of EEG monitoring. With respect to possible triggers for this event, his friends note that the patient has a longstanding history of heavy alcohol use "in bursts." He tends to drink when having a stressor or significant life event. Last week was the anniversary of his father's death, and friends report that "almost certainly" he drank heavily for at least the last week. They do not know when his last drink was, but do note that he seemed like himself when they spoke on the phone last night. To their knowledge, the patient has not been ill recently and has not had any recent head trauma. They do note that he has had one prior seizure in the past, that occurred at some point last year. This occurred while he was at the grocery store and was witnessed by bystanders. He is not followed by a neurologist and it was thought to be an isolated event. No further information is known about the seizure at this time. Currently, the patient is aware he is at a hospital and says "I'm here because they said I had seizures." He has no recollection of the events of the day. He reports he has been generally well apart from having rhinorrhea over the last few months. Denies any recent fevers, headaches, visual changes, nasal congestion or other respiratory symptoms. He denies any recent history of head trauma. Denies recent falls. Denies recent fever, chills or recent illness. Denies alcohol use (contrary to what is reported by friends) or drug use. Past Medical History: -History of seizure x1 -History of SVT per records. Friends report he followed by Cardiologist (Dr. ___, ___ due to his father's history of premature coronary disease. Social History: ___ Family History: History of MI in his father in ___. ___ any history of seizures, neurologic disorders or developmental delay in the family. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== General: Awake, disoriented. Smells of urine. HEENT: NC/AT, no scleral icterus noted, MMM, +visible evidence of tongue bruising with dried blood in mouth and on surface of tongue Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused; regular rhythm Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert. Oriented to self, hospital (not to ___, says he is at ___, and date. Able to say days of the week forwards and backwards. Able to say months of the year backwards with 2 errors. He is perseverative on wanting a glass of water. He is impulsive; at the conclusion of the interview, he jumped out of bed and urinated on the floor "because I had to go." Negative jaw jerk. He is able to answer some questions about his past history, but unable to provide history for recent events. 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 on the stroke card. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with ___ beats of bilateral end gaze nystagmus, which does extinguish. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3* 3 3 3** 2 R 3* 3 3 3** 2 *pectoralis jerk present **crossed adductors present Negative ___ Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. DISCHARGE PHYSICAL EXAM ======================= VS: 97.5, 118/76, 75, 20, 97%/RA GEN: NAD, lying comfortably in bed HEENT: PERRL, MMM, bite marks on tongue, EOMI, sclera anicteric, OP clear NECK: No LAD, no TM CARD: RRR, S1 + S2 present, no mrg RESP: CTAB, no wheezes/crackles ABD: SNTND, +BS, no HSM EXT: WWP, cool feet, PPP NEURO: CNII-XII intact, ___ strength in UE and ___ b/l, AOx3, ___ backwards, ambulating without difficulty down the hall Pertinent Results: ADMISSION LABS ============== ___ 06:00AM BLOOD WBC-7.2 RBC-4.18* Hgb-13.9 Hct-41.3 MCV-99* MCH-33.3* MCHC-33.7 RDW-13.7 RDWSD-50.2* Plt ___ ___ 09:10PM BLOOD WBC-9.0 RBC-4.10* Hgb-14.5 Hct-39.7* MCV-97 MCH-35.4* MCHC-36.5 RDW-13.8 RDWSD-49.1* Plt ___ ___ 09:10PM BLOOD ___ PTT-27.1 ___ ___ 06:00AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-139 K-3.5 Cl-102 HCO3-25 AnGap-16 ___ 09:10PM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-137 K-3.6 Cl-99 HCO3-21* AnGap-21* ___ 06:00AM BLOOD ALT-17 AST-60* LD(LDH)-415* AlkPhos-75 TotBili-0.5 ___ 09:10PM BLOOD Lipase-21 ___ 09:10PM BLOOD cTropnT-<0.01 ___ 06:00AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.6 Mg-1.8 ___ 04:40AM BLOOD TSH-1.9 ___ 09:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGES ====== ___ This is normal continuous ICU monitoring study. There were no pushbutton activations. There were no focal abnormalities, electrographic seizures, or epileptiform discharges. A tachycardia in the 140-150s bpm was noted by the end of the recording. ___ Head 1. No acute intracranial abnormality. 2. Patent intracranial arterial vasculature without significant stenosis, occlusion, or aneurysm. 3. No evidence of cerebral venous thrombosis. 4. Periapical lucency of a right maxillary molar consistent with periodontal disease. Formal dental evaluation is advised. CXR (___): In comparison with study of ___ from an outside facility, there is little change. Mild hyperexpansion of the lungs raises the possibility underlying chronic pulmonary disease. However, no acute pneumonia, vascular congestion, or pleural effusion. CXR (___): There are lower lung volumes. Bibasilar opacities larger on the left could represent atelectasis, or given the clinical history aspiration could present on the left. There is biapical pleural thickening. There is no pneumothorax or pleural effusion. Mild cardiomegaly is accentuated by the projection and low lung volumes MICRO ===== ___ Urine culture: negative ___ Blood culture: negative ___ Blood culture: negative DISCHARGE LABS ============== ___ 06:40AM BLOOD WBC-5.0 RBC-3.98* Hgb-13.4* Hct-40.4 MCV-102* MCH-33.7* MCHC-33.2 RDW-13.9 RDWSD-52.2* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-142 K-4.1 Cl-102 HCO3-28 AnGap-16 ___ 06:30AM BLOOD ALT-21 AST-82* LD(LDH)-547* CK(CPK)-4150* AlkPhos-78 TotBili-0.4 ___ 06:40AM BLOOD Calcium-8.9 Phos-5.3* Mg-2.___ with a PMH of alcohol use disorder and seizures related to alcohol use who p/w seizures iso alcohol withdrawal, course c/b c/b tactile hallucinations, autonomic instability, and delirium tremens for which he received a phenobarbital taper as well as rhabdomyolysis and narrow complex tachycardia, all of which had improved prior to discharge. #Seizure disorder: Pt was admitted to Neurology after three witnessed seizures. He was started on Keppra 1g BID and underwent CT Head at OSH and CTA which showed no acute intracranial abnormalities. He was monitored on cvEEG which did not show any acute epileptogenic abnormalities. Seizures were likely precipitated by alcohol use and/or withdrawal. Due to withdrawal, he was transferred to the MICU for phenobarb protocol as below. Pt was discharged on keppra 1g BID and should follow up with neurology as outpatient. # Alcohol Withdrawal, hallucinosis, delirium tremens: On admission pt developed EtOH withdrawal symptoms including tactile hallucinations and tachycardia/altered sensorium c/w DT. He was initially treated with Diazepam and Haldol, but he became increasingly agitated and then was transferred to the medical ICU for phenobarbital protocol. He was started on thiamine, folate and multivitamin. His agitation improved and his vital signs stabilized, after which he was transferred to the floor and monitored as he continued to improve. Keppra was continued as above. # SVT: On evening of ___, pt was seen to go into SVT (a chronic issue) which was resolved w/ Metoprolol and Diltiazem push. Likely attributable to withdrawal as well. This did not recur thereafter and he remained asymptomatic. # Toxic Metabolic Encephalopathy: Resolved on discharge. Most likely due to alcohol withdrawal as above. Infectious workup negative and neuro exam was nonfocal. # Rhabdomyolysis: Likely in the setting of seizure and subsequent muscle break-down. Downtrended with IVF, 4150 on ___ ___ on ___. Recommend repeat CK, lytes with PCP at follow up. # Alcohol use disorder: Pt has long hx of drinking that intensified after he was laid off in ___, drinks up to 1L rum daily. Pt has tried quitting before and has attended a partial program that he enjoyed in the past (about ___ years ago, maintained a couple months of sobriety). During admission pt stated interested in re-establishing a relationship with AA and attending a partial program. SW assisted with resources, and at discharge plan for AA meeting on day after discharge follow by partial program intake the day after. TRANSITIONAL ISSUES ================ [] Patient with thrombocytopenia thought secondary to chronic suppresion from alcohol use. Please re-check CBC at PCP appointment, and consider further work up. [] follow up with neurology regarding anti-epileptic medication [] STARTED Keppra 1 BID [] Consider disulfram (antabuse) vs other medications to prevent relapse if remains consistent with patient goals [] Pt may not drive for 6 months dating from his seizure (6 months from ___ # CODE: Full # CONTACT: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications 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. LevETIRAcetam 1000 mg PO Q12H RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 3. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 ___ one patch Daily Disp #*14 Patch Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================ Generalized tonic-clonic seizures Alcohol withdrawal Tactile hallucinations/alcoholic hallucinosis Delirium Tremens Narrow complex tachycardia Rhabdomyolysis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to be part of your care. You were admitted to the hospital because you were having a seizure after you had been ingesting alcohol. The seizure was likely due to alcohol withdrawal. You received medications to help stop the seizures and to prevent alcohol withdrawal symptoms. You were also started on a medication to prevent seizures (keppra) which you will need to continue when you leave the hospital. We would advise you to stop drinking any alcohol. The social work team came and spoke to you about partial programs that you could join and encouraged you to participate in AA meetings again. If you do drink and experience any symptoms of withdrawal including hallucinations or further seizures please seek medical attention. We wish you the best, Your ___ Team Followup Instructions: ___
[ "F10231", "G92", "M6282", "D696", "I471", "R569", "Z23" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Generalized tonic-clonic seizure Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] year-old man with history of a prior seizure in [MASKED] (unclear circumstances) and alcohol use who presents with three witnessed events concerning for seizure. The vast majority of the history is provided by the patient's two friends [MASKED] and [MASKED] and records, as the patient is unable to provide much history due to mental status. Per the patient's friends, Mr. [MASKED] was in his usual state of health until approximately 5:30PM this evening. He was watching TV with his mother, when she witnessed him "having a seizure." His mother called the friends to come see him. His friends note that the patient's mother has baseline cognitive/memory issues and is a poor historian; she was unable to give more information about what she saw. By the time the friends arrived approximately 10 minutes later, they note the patient was laying on the couch awake, but "staring glassy eyed", non verbal, and not responding to their questions. He had a small amount of blood visible in his mouth. Several minutes later, they witnessed his right arm extend above his head, turn his head to the right, make gurgling noise in his mouth and clench his teeth tightly. This was followed by shaking of the right arm, lasting "a few minutes." His friends were not sure whether the other three extremities were shaking at this time. They brought him to the floor and thought it was best to try to suppress the movements, so they held down all four extremities tightly. They called EMS. After the event, the patient remained confused as he was before. By the time EMS arrived, the patient had another event. This was characterized by stiffening of all four extremities followed by rapid shaking movements. This was associated with urinary incontinence and tongue biting. He was brought to [MASKED] and received 2mg of IV Ativan and 500cc NS en route. On arrival to [MASKED], the patient was initially noted to be nonverbal but responsive to painful stimuli. He received 1g of IV Keppra, and was transferred to [MASKED] for neurologic evaluation and consideration of EEG monitoring. With respect to possible triggers for this event, his friends note that the patient has a longstanding history of heavy alcohol use "in bursts." He tends to drink when having a stressor or significant life event. Last week was the anniversary of his father's death, and friends report that "almost certainly" he drank heavily for at least the last week. They do not know when his last drink was, but do note that he seemed like himself when they spoke on the phone last night. To their knowledge, the patient has not been ill recently and has not had any recent head trauma. They do note that he has had one prior seizure in the past, that occurred at some point last year. This occurred while he was at the grocery store and was witnessed by bystanders. He is not followed by a neurologist and it was thought to be an isolated event. No further information is known about the seizure at this time. Currently, the patient is aware he is at a hospital and says "I'm here because they said I had seizures." He has no recollection of the events of the day. He reports he has been generally well apart from having rhinorrhea over the last few months. Denies any recent fevers, headaches, visual changes, nasal congestion or other respiratory symptoms. He denies any recent history of head trauma. Denies recent falls. Denies recent fever, chills or recent illness. Denies alcohol use (contrary to what is reported by friends) or drug use. Past Medical History: -History of seizure x1 -History of SVT per records. Friends report he followed by Cardiologist (Dr. [MASKED], [MASKED] due to his father's history of premature coronary disease. Social History: [MASKED] Family History: History of MI in his father in [MASKED]. [MASKED] any history of seizures, neurologic disorders or developmental delay in the family. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== General: Awake, disoriented. Smells of urine. HEENT: NC/AT, no scleral icterus noted, MMM, +visible evidence of tongue bruising with dried blood in mouth and on surface of tongue Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused; regular rhythm Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert. Oriented to self, hospital (not to [MASKED], says he is at [MASKED], and date. Able to say days of the week forwards and backwards. Able to say months of the year backwards with 2 errors. He is perseverative on wanting a glass of water. He is impulsive; at the conclusion of the interview, he jumped out of bed and urinated on the floor "because I had to go." Negative jaw jerk. He is able to answer some questions about his past history, but unable to provide history for recent events. 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 on the stroke card. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with [MASKED] beats of bilateral end gaze nystagmus, which does extinguish. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] 5 [MASKED] 5 5 5 5 5 R 5 [MASKED] 5 [MASKED] 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 3* 3 3 3** 2 R 3* 3 3 3** 2 *pectoralis jerk present **crossed adductors present Negative [MASKED] Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. DISCHARGE PHYSICAL EXAM ======================= VS: 97.5, 118/76, 75, 20, 97%/RA GEN: NAD, lying comfortably in bed HEENT: PERRL, MMM, bite marks on tongue, EOMI, sclera anicteric, OP clear NECK: No LAD, no TM CARD: RRR, S1 + S2 present, no mrg RESP: CTAB, no wheezes/crackles ABD: SNTND, +BS, no HSM EXT: WWP, cool feet, PPP NEURO: CNII-XII intact, [MASKED] strength in UE and [MASKED] b/l, AOx3, [MASKED] backwards, ambulating without difficulty down the hall Pertinent Results: ADMISSION LABS ============== [MASKED] 06:00AM BLOOD WBC-7.2 RBC-4.18* Hgb-13.9 Hct-41.3 MCV-99* MCH-33.3* MCHC-33.7 RDW-13.7 RDWSD-50.2* Plt [MASKED] [MASKED] 09:10PM BLOOD WBC-9.0 RBC-4.10* Hgb-14.5 Hct-39.7* MCV-97 MCH-35.4* MCHC-36.5 RDW-13.8 RDWSD-49.1* Plt [MASKED] [MASKED] 09:10PM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 06:00AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-139 K-3.5 Cl-102 HCO3-25 AnGap-16 [MASKED] 09:10PM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-137 K-3.6 Cl-99 HCO3-21* AnGap-21* [MASKED] 06:00AM BLOOD ALT-17 AST-60* LD(LDH)-415* AlkPhos-75 TotBili-0.5 [MASKED] 09:10PM BLOOD Lipase-21 [MASKED] 09:10PM BLOOD cTropnT-<0.01 [MASKED] 06:00AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.6 Mg-1.8 [MASKED] 04:40AM BLOOD TSH-1.9 [MASKED] 09:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGES ====== [MASKED] This is normal continuous ICU monitoring study. There were no pushbutton activations. There were no focal abnormalities, electrographic seizures, or epileptiform discharges. A tachycardia in the 140-150s bpm was noted by the end of the recording. [MASKED] Head 1. No acute intracranial abnormality. 2. Patent intracranial arterial vasculature without significant stenosis, occlusion, or aneurysm. 3. No evidence of cerebral venous thrombosis. 4. Periapical lucency of a right maxillary molar consistent with periodontal disease. Formal dental evaluation is advised. CXR ([MASKED]): In comparison with study of [MASKED] from an outside facility, there is little change. Mild hyperexpansion of the lungs raises the possibility underlying chronic pulmonary disease. However, no acute pneumonia, vascular congestion, or pleural effusion. CXR ([MASKED]): There are lower lung volumes. Bibasilar opacities larger on the left could represent atelectasis, or given the clinical history aspiration could present on the left. There is biapical pleural thickening. There is no pneumothorax or pleural effusion. Mild cardiomegaly is accentuated by the projection and low lung volumes MICRO ===== [MASKED] Urine culture: negative [MASKED] Blood culture: negative [MASKED] Blood culture: negative DISCHARGE LABS ============== [MASKED] 06:40AM BLOOD WBC-5.0 RBC-3.98* Hgb-13.4* Hct-40.4 MCV-102* MCH-33.7* MCHC-33.2 RDW-13.9 RDWSD-52.2* Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-142 K-4.1 Cl-102 HCO3-28 AnGap-16 [MASKED] 06:30AM BLOOD ALT-21 AST-82* LD(LDH)-547* CK(CPK)-4150* AlkPhos-78 TotBili-0.4 [MASKED] 06:40AM BLOOD Calcium-8.9 Phos-5.3* Mg-2.[MASKED] with a PMH of alcohol use disorder and seizures related to alcohol use who p/w seizures iso alcohol withdrawal, course c/b c/b tactile hallucinations, autonomic instability, and delirium tremens for which he received a phenobarbital taper as well as rhabdomyolysis and narrow complex tachycardia, all of which had improved prior to discharge. #Seizure disorder: Pt was admitted to Neurology after three witnessed seizures. He was started on Keppra 1g BID and underwent CT Head at OSH and CTA which showed no acute intracranial abnormalities. He was monitored on cvEEG which did not show any acute epileptogenic abnormalities. Seizures were likely precipitated by alcohol use and/or withdrawal. Due to withdrawal, he was transferred to the MICU for phenobarb protocol as below. Pt was discharged on keppra 1g BID and should follow up with neurology as outpatient. # Alcohol Withdrawal, hallucinosis, delirium tremens: On admission pt developed EtOH withdrawal symptoms including tactile hallucinations and tachycardia/altered sensorium c/w DT. He was initially treated with Diazepam and Haldol, but he became increasingly agitated and then was transferred to the medical ICU for phenobarbital protocol. He was started on thiamine, folate and multivitamin. His agitation improved and his vital signs stabilized, after which he was transferred to the floor and monitored as he continued to improve. Keppra was continued as above. # SVT: On evening of [MASKED], pt was seen to go into SVT (a chronic issue) which was resolved w/ Metoprolol and Diltiazem push. Likely attributable to withdrawal as well. This did not recur thereafter and he remained asymptomatic. # Toxic Metabolic Encephalopathy: Resolved on discharge. Most likely due to alcohol withdrawal as above. Infectious workup negative and neuro exam was nonfocal. # Rhabdomyolysis: Likely in the setting of seizure and subsequent muscle break-down. Downtrended with IVF, 4150 on [MASKED] [MASKED] on [MASKED]. Recommend repeat CK, lytes with PCP at follow up. # Alcohol use disorder: Pt has long hx of drinking that intensified after he was laid off in [MASKED], drinks up to 1L rum daily. Pt has tried quitting before and has attended a partial program that he enjoyed in the past (about [MASKED] years ago, maintained a couple months of sobriety). During admission pt stated interested in re-establishing a relationship with AA and attending a partial program. SW assisted with resources, and at discharge plan for AA meeting on day after discharge follow by partial program intake the day after. TRANSITIONAL ISSUES ================ [] Patient with thrombocytopenia thought secondary to chronic suppresion from alcohol use. Please re-check CBC at PCP appointment, and consider further work up. [] follow up with neurology regarding anti-epileptic medication [] STARTED Keppra 1 BID [] Consider disulfram (antabuse) vs other medications to prevent relapse if remains consistent with patient goals [] Pt may not drive for 6 months dating from his seizure (6 months from [MASKED] # CODE: Full # CONTACT: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications 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. LevETIRAcetam 1000 mg PO Q12H RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 3. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 [MASKED] one patch Daily Disp #*14 Patch Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================ Generalized tonic-clonic seizures Alcohol withdrawal Tactile hallucinations/alcoholic hallucinosis Delirium Tremens Narrow complex tachycardia Rhabdomyolysis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure to be part of your care. You were admitted to the hospital because you were having a seizure after you had been ingesting alcohol. The seizure was likely due to alcohol withdrawal. You received medications to help stop the seizures and to prevent alcohol withdrawal symptoms. You were also started on a medication to prevent seizures (keppra) which you will need to continue when you leave the hospital. We would advise you to stop drinking any alcohol. The social work team came and spoke to you about partial programs that you could join and encouraged you to participate in AA meetings again. If you do drink and experience any symptoms of withdrawal including hallucinations or further seizures please seek medical attention. We wish you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D696" ]
[ "F10231: Alcohol dependence with withdrawal delirium", "G92: Toxic encephalopathy", "M6282: Rhabdomyolysis", "D696: Thrombocytopenia, unspecified", "I471: Supraventricular tachycardia", "R569: Unspecified convulsions", "Z23: Encounter for immunization" ]
10,058,868
25,385,222
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: seizures Major Surgical or Invasive Procedure: intubation, right hemiarthroplasty History of Present Illness: ___ year old male with a history of seizures transferred from OSH with status epilepticus. Patient reportedly was walking his dog when he was observed to have a seizure. Patient was transported to the OSH while somnolent and had another seizure en route. Patient without return to normal mental status and was intubated in the ED with succinylcholine and etomidate. On arrival to our ED, the patient is intubated and sedated on propofol. Per EMS, patient stopped taking keppra in the ___ and is not currently on any home medications. He received keppra 1g IV prior to transfer. Past Medical History: ETOH use disorder w/ w/drawal seizures SVT Social History: ___ Family History: Notable for MI in father in ___. No family history of seizures. Physical Exam: ADMISSION PHYSICAL EXAM: 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: soft, non-tender, non-distended, bowel sounds present, no ebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: =============== ___ 11:00PM BLOOD ___ PTT-23.5* ___ ___ 05:45AM BLOOD Glucose-109* UreaN-17 Creat-0.7 Na-142 K-3.6 Cl-101 HCO3-26 AnGap-15 ___ 11:00PM BLOOD CK(CPK)-493* ___ 05:45AM BLOOD Albumin-3.9 Calcium-8.2* Phos-5.0* Mg-1.8 ___ 11:35PM BLOOD Type-MIX pO2-27* pCO2-51* pH-7.32* calTCO2-27 Base XS--1 ___ 11:35PM BLOOD Glucose-106* Lactate-3.2* Na-138 K-3.3 Cl-98 DISCHARGE LABS: =============== IMAGING: ======= Hip X-Ray: There is a right subcapital femoral fracture. The distal fragment is mildly impacted, proximally displaced and varus angulated. Background mild degenerative changes at the right hip were seen. Mild left hip osteoarthritis also present. MRI Head: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. Generalized cerebral and cerebellar atrophy with associated ex vacuo dilatation of the ventricular system. A couple of periventricular and deep white matter T2 and FLAIR hyperintensities are nonspecific, but most likely represent sequela of microangiopathy. There is no abnormal enhancement after contrast administration. The hippocampi are symmetrical in volume and signal intensity. No obvious increase in T2 or FLAIR signal involving the mammillary bodies, thalami or periaqueductal area. Moderate mucosal thickening involving the paranasal sinuses. MICROBIOLOGY: ============= Blood Culture: ### Urine Culture: No growth Brief Hospital Course: Mr. ___ is a ___ w/ ETOH disorder presenting w/ seizure likely ___ ETOH w/drawal, also found to have right femoral neck fracture sustained during the convulsive episode. Early in his course, he went to SVT twice with heart rates in the 170s. Both times the SVT was successfully treated with adenosine pushes. Assessment and plan by problem: # ETOH w/drawal w/ seizures: Seizures are likely ___ ETOH w/drawal. Has had ETOH w/drawal seizures in the past. Required intubation in MICU on admission w/ phenobarbital loading. Neurology consulted for other etiology of seizure, EEG unremarkable. MRI w/o epileptic focus. Picture most consistent with etOH withdrawal seizures -Per Neurology: Continue levetiracetam 1000mg BID until seen in Neurology clinic. -Received Thiamine 500mg TID x3-5d (___) + folate 1mg QD. # SVT: 2 episodes now requiring adenosine. Cardiology consulted, started metoprolol tartrate 25mg PO BID which will be continued on d/c. Cardiology f/u on d/c. # ETOH Use Disorder: Interested in quitting, drinks 1L vodka daily. SW consulted. # Thrombocytopenia: Likely ___ chronic ETOH use. Monitored and can be followed as outpatient. # R femoral neck fracture The patient was taken to the operating room on ___ for right hemiarthroplasty, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on subcutaneous lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Enoxaparin Sodium 40 mg SC QPM RX *enoxaparin 40 mg/0.4 mL 40 units SC daily Disp #*26 Syringe Refills:*0 4. FoLIC Acid 1 mg IV Q24H 5. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 8. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg PO/NG BID Duration: 4 Doses Start: ___, First Dose: ___ This is dose # 1 of 4 tapered doses 9. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg PO/NG BID Duration: 4 Doses This is dose # 2 of 4 tapered doses 10. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 0 mg PO/NG BID Duration: 2 Doses Start: After 0 mg BID tapered dose This is dose # 3 of 4 tapered doses 11. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 6 mg PO/NG BID Duration: 2 Doses Start: After 0 mg BID tapered dose This is dose # 4 of 4 tapered doses RX *phenobarbital 15 mg 0.5 (One half) tablet(s) by mouth every twelve (12) hours Disp #*1 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Complicated alcohol withdrawal R femoral neck fracture Discharge Condition: AVSS NAD, A&Ox3 RLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: You were in the hospital for seizures, likely secondary to alcohol withdrawal, and a right femoral neck fracture. Please discuss options for alcohol cessation with your primary care physician. These include talk groups like Alcoholics Anonymous as well as pharmacologic options. 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: - WBAT RLE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
[ "S72011A", "E872", "D696", "I471", "F10239", "G40501", "W04XXXA", "Y9289" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: seizures Major Surgical or Invasive Procedure: intubation, right hemiarthroplasty History of Present Illness: [MASKED] year old male with a history of seizures transferred from OSH with status epilepticus. Patient reportedly was walking his dog when he was observed to have a seizure. Patient was transported to the OSH while somnolent and had another seizure en route. Patient without return to normal mental status and was intubated in the ED with succinylcholine and etomidate. On arrival to our ED, the patient is intubated and sedated on propofol. Per EMS, patient stopped taking keppra in the [MASKED] and is not currently on any home medications. He received keppra 1g IV prior to transfer. Past Medical History: ETOH use disorder w/ w/drawal seizures SVT Social History: [MASKED] Family History: Notable for MI in father in [MASKED]. No family history of seizures. Physical Exam: ADMISSION PHYSICAL EXAM: 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: soft, non-tender, non-distended, bowel sounds present, no ebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:00PM BLOOD [MASKED] PTT-23.5* [MASKED] [MASKED] 05:45AM BLOOD Glucose-109* UreaN-17 Creat-0.7 Na-142 K-3.6 Cl-101 HCO3-26 AnGap-15 [MASKED] 11:00PM BLOOD CK(CPK)-493* [MASKED] 05:45AM BLOOD Albumin-3.9 Calcium-8.2* Phos-5.0* Mg-1.8 [MASKED] 11:35PM BLOOD Type-MIX pO2-27* pCO2-51* pH-7.32* calTCO2-27 Base XS--1 [MASKED] 11:35PM BLOOD Glucose-106* Lactate-3.2* Na-138 K-3.3 Cl-98 DISCHARGE LABS: =============== IMAGING: ======= Hip X-Ray: There is a right subcapital femoral fracture. The distal fragment is mildly impacted, proximally displaced and varus angulated. Background mild degenerative changes at the right hip were seen. Mild left hip osteoarthritis also present. MRI Head: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. Generalized cerebral and cerebellar atrophy with associated ex vacuo dilatation of the ventricular system. A couple of periventricular and deep white matter T2 and FLAIR hyperintensities are nonspecific, but most likely represent sequela of microangiopathy. There is no abnormal enhancement after contrast administration. The hippocampi are symmetrical in volume and signal intensity. No obvious increase in T2 or FLAIR signal involving the mammillary bodies, thalami or periaqueductal area. Moderate mucosal thickening involving the paranasal sinuses. MICROBIOLOGY: ============= Blood Culture: ### Urine Culture: No growth Brief Hospital Course: Mr. [MASKED] is a [MASKED] w/ ETOH disorder presenting w/ seizure likely [MASKED] ETOH w/drawal, also found to have right femoral neck fracture sustained during the convulsive episode. Early in his course, he went to SVT twice with heart rates in the 170s. Both times the SVT was successfully treated with adenosine pushes. Assessment and plan by problem: # ETOH w/drawal w/ seizures: Seizures are likely [MASKED] ETOH w/drawal. Has had ETOH w/drawal seizures in the past. Required intubation in MICU on admission w/ phenobarbital loading. Neurology consulted for other etiology of seizure, EEG unremarkable. MRI w/o epileptic focus. Picture most consistent with etOH withdrawal seizures -Per Neurology: Continue levetiracetam 1000mg BID until seen in Neurology clinic. -Received Thiamine 500mg TID x3-5d ([MASKED]) + folate 1mg QD. # SVT: 2 episodes now requiring adenosine. Cardiology consulted, started metoprolol tartrate 25mg PO BID which will be continued on d/c. Cardiology f/u on d/c. # ETOH Use Disorder: Interested in quitting, drinks 1L vodka daily. SW consulted. # Thrombocytopenia: Likely [MASKED] chronic ETOH use. Monitored and can be followed as outpatient. # R femoral neck fracture The patient was taken to the operating room on [MASKED] for right hemiarthroplasty, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on subcutaneous lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Enoxaparin Sodium 40 mg SC QPM RX *enoxaparin 40 mg/0.4 mL 40 units SC daily Disp #*26 Syringe Refills:*0 4. FoLIC Acid 1 mg IV Q24H 5. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 8. PHENObarbital Alcohol Withdrawal Dose Taper (Days [MASKED] 0 mg PO/NG BID Duration: 4 Doses Start: [MASKED], First Dose: [MASKED] This is dose # 1 of 4 tapered doses 9. PHENObarbital Alcohol Withdrawal Dose Taper (Days [MASKED] 0 mg PO/NG BID Duration: 4 Doses This is dose # 2 of 4 tapered doses 10. PHENObarbital Alcohol Withdrawal Dose Taper (Days [MASKED] 0 mg PO/NG BID Duration: 2 Doses Start: After 0 mg BID tapered dose This is dose # 3 of 4 tapered doses 11. PHENObarbital Alcohol Withdrawal Dose Taper (Days [MASKED] 6 mg PO/NG BID Duration: 2 Doses Start: After 0 mg BID tapered dose This is dose # 4 of 4 tapered doses RX *phenobarbital 15 mg 0.5 (One half) tablet(s) by mouth every twelve (12) hours Disp #*1 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Complicated alcohol withdrawal R femoral neck fracture Discharge Condition: AVSS NAD, A&Ox3 RLE: Incision well approximated. Dressing clean and dry. Fires FHL, [MASKED], TA, GCS. SILT [MASKED] n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: You were in the hospital for seizures, likely secondary to alcohol withdrawal, and a right femoral neck fracture. Please discuss options for alcohol cessation with your primary care physician. These include talk groups like Alcoholics Anonymous as well as pharmacologic options. 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: - WBAT RLE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: [MASKED]
[]
[ "E872", "D696" ]
[ "S72011A: Unspecified intracapsular fracture of right femur, initial encounter for closed fracture", "E872: Acidosis", "D696: Thrombocytopenia, unspecified", "I471: Supraventricular tachycardia", "F10239: Alcohol dependence with withdrawal, unspecified", "G40501: Epileptic seizures related to external causes, not intractable, with status epilepticus", "W04XXXA: Fall while being carried or supported by other persons, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause" ]
10,058,910
22,302,368
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___: laparoscopic cholecystectomy History of Present Illness: ___ year old female presents to the hospital with abd pain. She also reports n/v/d and back pain. She had been evaluated at an OSH on ___ and diagnosed with food poisoning. The sx temporarily resolved on ___ until ___ night whenthey started again. She suspects she may have eaten an undercooked burger that night. She denies fevers, dysuria, weakness, numbness, or urinary incontinence. She is due to get a period now and denies any recent unprotected sex, sick contacts, or recent travel. Past Medical History: chronic UTIs Social History: ___ Family History: non-contributory Physical Exam: Physical Exam: upon admission: ___ Vitals: T 99.1 HR 84 BP 167/83 RR 18 O2 100%onRA Pain ___ GEN: A&Ox3, pleasant female in moderate distress HEENT: No scleral icterus, mucus membranes moist, CV: regular, no M/R/G PULM: CTA b/l, no labored breathing Abd: soft, non distended, TTP at RUQ ,no positive ___ sings, no rebound or guarding ext: warm and well perfused Physical examination upon discharge: ___: vital signs: t=99.5, hr=70, bp=120/68, rr=18, oxygen saturation=100% CV: ns1, s2, no murmurs LUNGS: clear ABDOOMEN: soft, tender, hypoactive BS, DSD to port sites EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 04:45AM BLOOD WBC-9.6 RBC-3.70* Hgb-10.2* Hct-32.2* MCV-87 MCH-27.6 MCHC-31.7* RDW-13.7 RDWSD-43.3 Plt ___ ___ 10:55PM BLOOD WBC-15.1* RBC-4.75 Hgb-13.1 Hct-40.1 MCV-84 MCH-27.6 MCHC-32.7 RDW-13.5 RDWSD-41.9 Plt ___ ___ 04:45AM BLOOD Plt ___ ___ 10:55PM BLOOD ___ PTT-33.5 ___ ___ 04:45AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-136 K-3.5 Cl-102 HCO3-25 AnGap-13 ___ 04:45AM BLOOD ALT-36 AST-29 AlkPhos-31* Amylase-47 TotBili-0.5 ___ 04:45AM BLOOD Lipase-30 ___ 04:45AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.0 ___: liver/gallbladder US: Distended gallbladder with sludge and a stone lodged at the gallbladder neck with associated gallbladder wall edema, concerning for acute cholecystitis in the proper clinical setting. Brief Hospital Course: ___ year old female admitted to the hospital with abdominal pain. Upon admission, she was made NPO, given intravenous fluids, and underwent imaging. An ultrasound of the liver and gallbladder was done which showed a distended gallbladder concerning for cholecystitis. Her liver function tests were normal. Based on these findings, the patient was taken to the operating room where she underwent a laparoscopic cholecystectomy. The operative course was stable with minimal blood loss. The patient was extubated after the procedure and monitored in the recovery room. The post-operative course was stable. The patient resumed a regular diet and was voiding without difficulty. Her incisional pain was controlled with oral analgesia. Her vital signs were stable and she was afebrile. The patient was discharged home on POD #1 in stable condition. An appointment for follow-up was made in the acute care clinic. Post-operative instructions were reviewed including signs and symptoms of infection. Medications on Admission: OCP Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: acute 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 hospital with abdominal pain, nausea, and vomiting. You underwent imaging and you were reported to have an inflamed gallbladder. You were taken to the operating room to have your gallbladder removed. You are recovering from your surgery and you are preparing for discharge home with the following instructions: You were admitted to the hospital with acute cholecystitis. 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. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. 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. You may start some light exercise when you feel comfortable. 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: You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. 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: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steristrips. 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). Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. 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. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. 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. If you are experiencing no pain, it is okay to skip a dose of pain medicine. 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. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: ___
[ "K8012" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [MASKED]: laparoscopic cholecystectomy History of Present Illness: [MASKED] year old female presents to the hospital with abd pain. She also reports n/v/d and back pain. She had been evaluated at an OSH on [MASKED] and diagnosed with food poisoning. The sx temporarily resolved on [MASKED] until [MASKED] night whenthey started again. She suspects she may have eaten an undercooked burger that night. She denies fevers, dysuria, weakness, numbness, or urinary incontinence. She is due to get a period now and denies any recent unprotected sex, sick contacts, or recent travel. Past Medical History: chronic UTIs Social History: [MASKED] Family History: non-contributory Physical Exam: Physical Exam: upon admission: [MASKED] Vitals: T 99.1 HR 84 BP 167/83 RR 18 O2 100%onRA Pain [MASKED] GEN: A&Ox3, pleasant female in moderate distress HEENT: No scleral icterus, mucus membranes moist, CV: regular, no M/R/G PULM: CTA b/l, no labored breathing Abd: soft, non distended, TTP at RUQ ,no positive [MASKED] sings, no rebound or guarding ext: warm and well perfused Physical examination upon discharge: [MASKED]: vital signs: t=99.5, hr=70, bp=120/68, rr=18, oxygen saturation=100% CV: ns1, s2, no murmurs LUNGS: clear ABDOOMEN: soft, tender, hypoactive BS, DSD to port sites EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear Pertinent Results: [MASKED] 04:45AM BLOOD WBC-9.6 RBC-3.70* Hgb-10.2* Hct-32.2* MCV-87 MCH-27.6 MCHC-31.7* RDW-13.7 RDWSD-43.3 Plt [MASKED] [MASKED] 10:55PM BLOOD WBC-15.1* RBC-4.75 Hgb-13.1 Hct-40.1 MCV-84 MCH-27.6 MCHC-32.7 RDW-13.5 RDWSD-41.9 Plt [MASKED] [MASKED] 04:45AM BLOOD Plt [MASKED] [MASKED] 10:55PM BLOOD [MASKED] PTT-33.5 [MASKED] [MASKED] 04:45AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-136 K-3.5 Cl-102 HCO3-25 AnGap-13 [MASKED] 04:45AM BLOOD ALT-36 AST-29 AlkPhos-31* Amylase-47 TotBili-0.5 [MASKED] 04:45AM BLOOD Lipase-30 [MASKED] 04:45AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.0 [MASKED]: liver/gallbladder US: Distended gallbladder with sludge and a stone lodged at the gallbladder neck with associated gallbladder wall edema, concerning for acute cholecystitis in the proper clinical setting. Brief Hospital Course: [MASKED] year old female admitted to the hospital with abdominal pain. Upon admission, she was made NPO, given intravenous fluids, and underwent imaging. An ultrasound of the liver and gallbladder was done which showed a distended gallbladder concerning for cholecystitis. Her liver function tests were normal. Based on these findings, the patient was taken to the operating room where she underwent a laparoscopic cholecystectomy. The operative course was stable with minimal blood loss. The patient was extubated after the procedure and monitored in the recovery room. The post-operative course was stable. The patient resumed a regular diet and was voiding without difficulty. Her incisional pain was controlled with oral analgesia. Her vital signs were stable and she was afebrile. The patient was discharged home on POD #1 in stable condition. An appointment for follow-up was made in the acute care clinic. Post-operative instructions were reviewed including signs and symptoms of infection. Medications on Admission: OCP Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: acute 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 hospital with abdominal pain, nausea, and vomiting. You underwent imaging and you were reported to have an inflamed gallbladder. You were taken to the operating room to have your gallbladder removed. You are recovering from your surgery and you are preparing for discharge home with the following instructions: You were admitted to the hospital with acute cholecystitis. 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. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. 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. You may start some light exercise when you feel comfortable. 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: You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. 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: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steristrips. 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). Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. 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. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. 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. If you are experiencing no pain, it is okay to skip a dose of pain medicine. 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. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: [MASKED]
[]
[]
[ "K8012: Calculus of gallbladder with acute and chronic cholecystitis without obstruction" ]
10,059,041
22,386,234
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: morphine / amlodipine Attending: ___ ___ Complaint: Left knee stiffness Major Surgical or Invasive Procedure: ___: Left knee manipulation under anesthesia History of Present Illness: ___ s/p L TKR c/b stiffness now s/p L knee MUA Past Medical History: PAST MEDICAL HISTORY: Significant for hypertension. Significant for mini strokes back in ___. PAST SURGICAL HISTORY: ___, right total knee replacement. Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: None 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. Postoperative course was unremarkable. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient was seen by physical therapy. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity, no range of motion restrictions. Ms. ___ is discharged to home in stable condition. Medications on Admission: 1. Lisinopril 40 mg PO BID 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Apixaban 5 mg PO QD 4. Omeprazole 20 mg PO DAILY 5. TraZODone 50 mg PO QHS Discharge Medications: 1. Apixaban 5 mg PO QD 2. Lisinopril 40 mg PO BID 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. TraZODone 50 mg PO QHS 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Left knee stiffness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Apixaban. Follow up with your Cardiologist. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 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. - CPM -5 to 120 setting whenever in bed Physical Therapy: WBAT, ROMAT CPM machine setting -5 to 120 whenever in bed Treatments Frequency: WBAT, ROMAT CPM machine setting -5 to 120 whenever in bed Followup Instructions: ___
[ "M24662", "Z96652", "I10", "Z8673", "Z7902", "E785", "M479", "M170", "K219" ]
Allergies: morphine / amlodipine [MASKED] Complaint: Left knee stiffness Major Surgical or Invasive Procedure: [MASKED]: Left knee manipulation under anesthesia History of Present Illness: [MASKED] s/p L TKR c/b stiffness now s/p L knee MUA Past Medical History: PAST MEDICAL HISTORY: Significant for hypertension. Significant for mini strokes back in [MASKED]. PAST SURGICAL HISTORY: [MASKED], right total knee replacement. Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: None 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. Postoperative course was unremarkable. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient was seen by physical therapy. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity, no range of motion restrictions. Ms. [MASKED] is discharged to home in stable condition. Medications on Admission: 1. Lisinopril 40 mg PO BID 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Apixaban 5 mg PO QD 4. Omeprazole 20 mg PO DAILY 5. TraZODone 50 mg PO QHS Discharge Medications: 1. Apixaban 5 mg PO QD 2. Lisinopril 40 mg PO BID 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. TraZODone 50 mg PO QHS 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Left knee stiffness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Apixaban. Follow up with your Cardiologist. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 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. - CPM -5 to 120 setting whenever in bed Physical Therapy: WBAT, ROMAT CPM machine setting -5 to 120 whenever in bed Treatments Frequency: WBAT, ROMAT CPM machine setting -5 to 120 whenever in bed Followup Instructions: [MASKED]
[]
[ "I10", "Z8673", "Z7902", "E785", "K219" ]
[ "M24662: Ankylosis, left knee", "Z96652: Presence of left artificial knee joint", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E785: Hyperlipidemia, unspecified", "M479: Spondylosis, unspecified", "M170: Bilateral primary osteoarthritis of knee", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,059,192
22,072,744
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: erythromycin base / morphine Attending: ___. Chief Complaint: CC: N/V/diarrhea x4 days Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ with hx of stage III colon cancer s/p hemicolectomy and adjuvant chemotherapy (___), chronic diarrhea, recent prolonged hospitalization at ___ ___ then ___ for complicated diverticulitis, with course complicated by weakness and poor PO intake attributed to severe depression, s/p PEG tube placement presenting with N/V, diarrhea, and abdominal pain x4 days. Of note, she has a known colovaginal fistula for which she has been followed by Dr. ___ current plan is for conservative management given high risk of operative management and no major complications of fistula to date. Pt reports ___ episodes of nonbloody emesis per day x4 days, with associated lower abdominal pain, ___, aching pain, and change in color of chronic diarrhea. She initially denies chills, although subsequently endorses. Pt reports that her tube feeds were discontinued ___ days prior to presentation, because she had achieved her goal weight, but says that she has been unable to take PO since ___ above symptoms. Transfer records confirm discontinuation of TFs on ___. She does endorse greenish vaginal discharge x2 months. She currently resides at ___ at ___, and has stayed there since ___, after discharge from ___. Per transfer notes from ___, pt had fever 99.1-101.6 in association with N/V, diarrhea and anorexia. She initially presented to ___, where she was found to have: Na 134 BUN 32 Cr 1.21 WBC 9.3 with 36% bands Hct 32.1 Plt 301 ALT 11 AST 12 Alk phos 66 Tbili 0.8 Lipase 13 Albumin 2.7 CT abd/pelvis revealed chronic findings including known colovaginal fistula, as well as acute distal ileitis, which is new compared to prior. She received vancomycin and zosyn, and was evaluated by surgery, who advised transfer to ___ for higher level of care. In the ___ ED: VS 98.3, 63, 113/52, 96% RA Exam notable for Labs notable for WBC 8.3 (10 bands), Hb 9.5, plt 236 BUN 28, Cr 1.1 INR 1.2 Lactate 1.2 Received: IVF Cipro/flagyl On arrival to the floor, pt is sleeping comfortably after having 2 liquid BMs in bed. She has no complaints, stating only that she is tired. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: - Stage III colon cancer previously followed by Dr. ___ s/p right hemicolectomy in ___ with adjuvant chemotherapy ___ and leucovorin - GERD - Asthma - Anxiety - Acute diverticulitis with abscess - Acute renal failure - Chronic diarrhea Social History: ___ Family History: No family hx of malignancy Physical Exam: Admission Exam: VS: ___ 0236 Temp: 98.5 PO BP: 116/62 R Lying HR: 65 RR: 18 O2 sat: 97% O2 delivery: Ra GEN: elderly, frail appearing female, alert and interactive, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, diffuse mild TTP although inconsistent - initially denies pain at R abdomen, endorses pain with deep palpation at LLQ and LUQ, subsequently endorses pain with deep palpation at R periumbilical region, no rebound or guarding, nondistended with normal active bowel sounds, no hepatomegaly. PEG in place with dressing c/d/I, no surrounding erythema or drainage. EXTREMITIES: no clubbing, cyanosis, or edema, 1+ DPs bilaterally GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3. Declines to try months of the year or days of the week in reverse, stating "I just did it, now I'm too tired." cranial nerves II-XII grossly intact, strength and sensation grossly intact. PSYCH: blunted affect Discharge Exam: VS: ___ 0717 Temp: 97.8 PO BP: 130/69 HR: 60 RR: 16 O2 sat: 98% O2 delivery: Ra GEN: comfortable, no complaints HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: SNTND, no HSM. Hyperactive BS. G-tube in situ, c/d/i, nonTTP around site. EXTREMITIES: no clubbing, cyanosis, or edema, 1+ DPs bilaterally GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3. Appropriate affect. Brief Hospital Course: ___ with hx of stage III colon cancer s/p hemicolectomy and adjuvant chemotherapy (___), chronic diarrhea, complicated diverticulitis s/p PEG tube placement presenting with N/V, diarrhea, and abdominal pain x4 days found to have terminal ileitis. # N/V: # Acute on chronic diarrhea: # Acute ileitis: # Fever: # Bandemia: # Recurrent diverticulitis with improving abscesses: # Colovaginal fistula: Not a surgical candidate. Discussed w/ ___ and patient, and everyone agrees that surgery is not a good option for this patient in the future. Her Cdiff toxin returned negative, and her diarrhea decreased after 24hrs of antibiotics. She was transitioned to PO cipro/flagyl, will complete 14d course (last day ___. At time of discharge, she was tolerating food, no n/v or abdominal pain. # Depression: # Hx of FTT: Extensive prior history. See prior notes, documentation in H&P at time of admission. Currently non-concerning. No events during admission. # CAD: Hx of CAD based on dobutamine stress from ___ which demonstrated probable prior MI based on basal inferolateral akinesis. At that time, patient was started on ASA 81mg, metoprolol XL 25mg and continued on her home statin. Per transfer records from ___, Metoprolol has since been discontinued, likely ___ HR in the ___. - Continue ___ - Continue atorvastatin # Anemia: At baseline, no further workup indicated at this time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin ___ mcg PO DAILY 3. FLUoxetine 30 mg PO DAILY 4. LOPERamide 2 mg PO QID:PRN Diarrhea 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 500 mg PO QID:PRN GERD 9. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 10. MethylPHENIDATE (Ritalin) 5 mg PO BID 11. Mirtazapine 15 mg PO QHS 12. Omeprazole 40 mg PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*26 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*39 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcium Carbonate 500 mg PO QID:PRN GERD 7. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 8. Cyanocobalamin ___ mcg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. FLUoxetine 30 mg PO DAILY 11. LOPERamide 2 mg PO QID:PRN Diarrhea 12. MethylPHENIDATE (Ritalin) 5 mg PO BID 13. Mirtazapine 15 mg PO QHS 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Ileitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, We admitted you for an infection in your gut. You are now doing better, so can go home to complete your course of oral antibiotics. We wish you the best with your health. Warm regards, ___ Medicine Followup Instructions: ___
[ "A09", "N824", "K5780", "K219", "J45909", "F419", "I2510", "R630", "D649", "I252", "Z85038", "Z9049", "Z66", "Z6823" ]
Allergies: erythromycin base / morphine Chief Complaint: CC: N/V/diarrhea x4 days Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] with hx of stage III colon cancer s/p hemicolectomy and adjuvant chemotherapy ([MASKED]), chronic diarrhea, recent prolonged hospitalization at [MASKED] [MASKED] then [MASKED] for complicated diverticulitis, with course complicated by weakness and poor PO intake attributed to severe depression, s/p PEG tube placement presenting with N/V, diarrhea, and abdominal pain x4 days. Of note, she has a known colovaginal fistula for which she has been followed by Dr. [MASKED] current plan is for conservative management given high risk of operative management and no major complications of fistula to date. Pt reports [MASKED] episodes of nonbloody emesis per day x4 days, with associated lower abdominal pain, [MASKED], aching pain, and change in color of chronic diarrhea. She initially denies chills, although subsequently endorses. Pt reports that her tube feeds were discontinued [MASKED] days prior to presentation, because she had achieved her goal weight, but says that she has been unable to take PO since [MASKED] above symptoms. Transfer records confirm discontinuation of TFs on [MASKED]. She does endorse greenish vaginal discharge x2 months. She currently resides at [MASKED] at [MASKED], and has stayed there since [MASKED], after discharge from [MASKED]. Per transfer notes from [MASKED], pt had fever 99.1-101.6 in association with N/V, diarrhea and anorexia. She initially presented to [MASKED], where she was found to have: Na 134 BUN 32 Cr 1.21 WBC 9.3 with 36% bands Hct 32.1 Plt 301 ALT 11 AST 12 Alk phos 66 Tbili 0.8 Lipase 13 Albumin 2.7 CT abd/pelvis revealed chronic findings including known colovaginal fistula, as well as acute distal ileitis, which is new compared to prior. She received vancomycin and zosyn, and was evaluated by surgery, who advised transfer to [MASKED] for higher level of care. In the [MASKED] ED: VS 98.3, 63, 113/52, 96% RA Exam notable for Labs notable for WBC 8.3 (10 bands), Hb 9.5, plt 236 BUN 28, Cr 1.1 INR 1.2 Lactate 1.2 Received: IVF Cipro/flagyl On arrival to the floor, pt is sleeping comfortably after having 2 liquid BMs in bed. She has no complaints, stating only that she is tired. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: - Stage III colon cancer previously followed by Dr. [MASKED] s/p right hemicolectomy in [MASKED] with adjuvant chemotherapy [MASKED] and leucovorin - GERD - Asthma - Anxiety - Acute diverticulitis with abscess - Acute renal failure - Chronic diarrhea Social History: [MASKED] Family History: No family hx of malignancy Physical Exam: Admission Exam: VS: [MASKED] 0236 Temp: 98.5 PO BP: 116/62 R Lying HR: 65 RR: 18 O2 sat: 97% O2 delivery: Ra GEN: elderly, frail appearing female, alert and interactive, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, diffuse mild TTP although inconsistent - initially denies pain at R abdomen, endorses pain with deep palpation at LLQ and LUQ, subsequently endorses pain with deep palpation at R periumbilical region, no rebound or guarding, nondistended with normal active bowel sounds, no hepatomegaly. PEG in place with dressing c/d/I, no surrounding erythema or drainage. EXTREMITIES: no clubbing, cyanosis, or edema, 1+ DPs bilaterally GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3. Declines to try months of the year or days of the week in reverse, stating "I just did it, now I'm too tired." cranial nerves II-XII grossly intact, strength and sensation grossly intact. PSYCH: blunted affect Discharge Exam: VS: [MASKED] 0717 Temp: 97.8 PO BP: 130/69 HR: 60 RR: 16 O2 sat: 98% O2 delivery: Ra GEN: comfortable, no complaints HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: SNTND, no HSM. Hyperactive BS. G-tube in situ, c/d/i, nonTTP around site. EXTREMITIES: no clubbing, cyanosis, or edema, 1+ DPs bilaterally GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3. Appropriate affect. Brief Hospital Course: [MASKED] with hx of stage III colon cancer s/p hemicolectomy and adjuvant chemotherapy ([MASKED]), chronic diarrhea, complicated diverticulitis s/p PEG tube placement presenting with N/V, diarrhea, and abdominal pain x4 days found to have terminal ileitis. # N/V: # Acute on chronic diarrhea: # Acute ileitis: # Fever: # Bandemia: # Recurrent diverticulitis with improving abscesses: # Colovaginal fistula: Not a surgical candidate. Discussed w/ [MASKED] and patient, and everyone agrees that surgery is not a good option for this patient in the future. Her Cdiff toxin returned negative, and her diarrhea decreased after 24hrs of antibiotics. She was transitioned to PO cipro/flagyl, will complete 14d course (last day [MASKED]. At time of discharge, she was tolerating food, no n/v or abdominal pain. # Depression: # Hx of FTT: Extensive prior history. See prior notes, documentation in H&P at time of admission. Currently non-concerning. No events during admission. # CAD: Hx of CAD based on dobutamine stress from [MASKED] which demonstrated probable prior MI based on basal inferolateral akinesis. At that time, patient was started on ASA 81mg, metoprolol XL 25mg and continued on her home statin. Per transfer records from [MASKED], Metoprolol has since been discontinued, likely [MASKED] HR in the [MASKED]. - Continue [MASKED] - Continue atorvastatin # Anemia: At baseline, no further workup indicated at this time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin [MASKED] mcg PO DAILY 3. FLUoxetine 30 mg PO DAILY 4. LOPERamide 2 mg PO QID:PRN Diarrhea 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 500 mg PO QID:PRN GERD 9. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 10. MethylPHENIDATE (Ritalin) 5 mg PO BID 11. Mirtazapine 15 mg PO QHS 12. Omeprazole 40 mg PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*26 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*39 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcium Carbonate 500 mg PO QID:PRN GERD 7. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 8. Cyanocobalamin [MASKED] mcg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. FLUoxetine 30 mg PO DAILY 11. LOPERamide 2 mg PO QID:PRN Diarrhea 12. MethylPHENIDATE (Ritalin) 5 mg PO BID 13. Mirtazapine 15 mg PO QHS 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Ileitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], We admitted you for an infection in your gut. You are now doing better, so can go home to complete your course of oral antibiotics. We wish you the best with your health. Warm regards, [MASKED] Medicine Followup Instructions: [MASKED]
[]
[ "K219", "J45909", "F419", "I2510", "D649", "I252", "Z66" ]
[ "A09: Infectious gastroenteritis and colitis, unspecified", "N824: Other female intestinal-genital tract fistulae", "K5780: Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R630: Anorexia", "D649: Anemia, unspecified", "I252: Old myocardial infarction", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z9049: Acquired absence of other specified parts of digestive tract", "Z66: Do not resuscitate", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]
10,059,192
24,721,736
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: erythromycin base / morphine Attending: ___ Chief Complaint: Weakness/Diarrhea Major Surgical or Invasive Procedure: ___: Failed ___ guided intrabdominal abscess drainage History of Present Illness: ___ year old woman with history of stage II colon cancer s/p right hemicolectomy and chemo (___), chronic diarrhea, recent admission at ___ (___) with complicated diverticulitis with abscess s/p incomplete ___ drainage, who presents as transfer from ___ with abdominal pain and complicated diverticulitis found to have new abscesses. In recent ___ admission (___), she was found to have acute complicated diverticulitis with intra-abdominal fluid collections suspicious for abscesses. ___ drain was placed in pelvic collection, and it was draining frank pus. She was then sent to rehab (___ in ___ due to her leg weakness. By the end of her rehab stay, she was having a great of difficult walking, as well as diarrhea and a decreased appetite. She then went from her rehab to live with her daughter ___, her HCP, on ___. She had ___ services there but given her difficulty walking and weakness, her daughter did not feel comfortable caring for her. From her daughter's home, she went to ___ ___ due to her weakness. Per the daughter, she was observed for two days then sent to ___ in ___. The rehab facility physician was concerned about her nausea, vomiting, poor PO intake, and weakness and sent her to ___ ___ again. Patient initially presented to ___ with reported concern of ongoing left lower quadrant abdominal pain and ongoing diarrhea. However, the patient denies ever endorsing abdominal pain and her HCP confirmed this. She has a complicated colonic history with prior recurrent C. difficile with recent test reportedly negative, prior episode of diverticulitis that was complicated by multiple loculated fluid collections requiring percutaneous drainage. She has a history of colon cancer and is followed by Dr. ___ in the setting of prior partial colonic resection. At ___, she was noted to be hypokalemic and hypomagnesemic which were both repleted and was found to have mild ___. Patient also found to be somewhat confused, assumed to be metabolic encephalopathy. Patient was covered with Zosyn and Flagyl and transferred to ___ by request by patient as she is followed here by colorectal surgery. In the ED, initial vitals: 97.5 76 154/60 16 96% RA Exam notable for: Somewhat confused. Abdomen soft, non-distended, non-tender Labs notable for: K 3.3, lactate 1.4, WBC 5.7, Imaging notable for: OSH CT Abd/pelvis read: There is an end to side ilio colic anastomosis seen in the anterior abdomen. The residual colon is significantly tortuous. There is extensive diverticulosis. There is some wall thickening in the sigmoid colon. Along the right aspect of the sigmoid colon, adjacent to the uterine fundus and inseparable from the fundus there is a fluid collection with air-fluid level measuring 2.9Ã-2.4Ã-2.1 cm. Additional collection along the posterior aspect the uterus measuring 3.4Ã-2.5Ã-2.4 cm. A large deep pelvic collection is seen along the undersurface of the sigmoid colon, measuring 11.7Ã-8.8Ã-5.0 cm. Some pelvic stranding is seen. Pt given: OSH gave patient IV zosyn and flagyl ___ 04:01 IV Ciprofloxacin 400 mg ___ 09:14 IV MetroNIDAZOLE 500mg ___ 09:14 IVF NS Started 125 mL/hr ___ 10:51 IV Ondansetron 4 mg Colorectal surgery saw the patient and wanted to continue IV zosyn and vancomycin. They want to talk to ___ about drainage of her abscesses. On the floor, the patient says she has been having trouble walking over the last month that has been progressive. She was not able to say if her weakness was secondary to dizziness or decreased strength but thinks it is more decreased strength. She endorsed nausea and vomiting as well as a decreased appetite. She has lost weight in the past few weeks but she is unsure of how much. She has been having ___ episodes of diarrhea daily but says this is normal for her and has been occurring for the past few months. She also has urinary incontinence at baseline for the past few years and wears diapers at home. She endorsed night sweats for the past few years but no fevers, chills, SOB, chest pain, abdominal pain, melena, BRBPR, dysuria, or decreased sensation/tingling in her extremities. Past Medical History: - Stage III colon cancer previously followed by Dr. ___ s/p right hemicolectomy in ___ with adjuvant chemotherapy ___ and leucovorin - GERD - Asthma - Anxiety - Acute diverticulitis with abscess - Acute renal failure - Chronic diarrhea Social History: ___ Family History: No family hx of malignancy Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VITALS: 98.5 PO 158 / 90 65 18 98 ra GENERAL: alert and oriented x 3, no acute distress but tired and chronically ill, hard of hearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities, intact sensation to light touch in ___ Lower extremities, 2+ reflexes bilaterally. =============================== DISCHARGE PHYSICAL EXAMINATION: =============================== VS: ___ 0433 Temp: 99.0 PO BP: 125/66 HR: 67 RR: 18 O2 sat: 95% O2 delivery: Ra GENERAL: NAD sitting up in bed NECK: supple CV: RRR, S1 and S2 normal RESP: CTAB, no wheeze/crackles ABD: No abdominal tenderness, no rash, erythema, or purulence around PEG. EXTREMITIES: Warm and well perfused, no lower extremity edema SKIN: No rashes visible NEURO: A/O x3, CNII-XII grossly intact Pertinent Results: =============== ADMISSION LABS: =============== ___ 02:05AM BLOOD WBC-5.7 RBC-4.69# Hgb-12.6# Hct-39.3# MCV-84 MCH-26.9 MCHC-32.1 RDW-15.9* RDWSD-48.4* Plt ___ ___ 02:05AM BLOOD Neuts-45.3 ___ Monos-10.0 Eos-2.8 Baso-1.1* Im ___ AbsNeut-2.59 AbsLymp-2.32 AbsMono-0.57 AbsEos-0.16 AbsBaso-0.06 ___ 02:05AM BLOOD ___ PTT-26.0 ___ ___ 02:05AM BLOOD Plt ___ ___ 02:05AM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-137 K-4.3 Cl-95* HCO3-22 AnGap-20* ___ 02:05AM BLOOD ALT-6 AST-32 AlkPhos-44 TotBili-0.5 ___ 07:10PM BLOOD cTropnT-<0.01 ___ 02:05AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 ___ 07:10PM BLOOD TSH-1.3 ___ 02:26AM BLOOD Lactate-1.4 K-3.3 ========================= PERTINENT INTERVAL LABS: ========================= ___ 07:54AM BLOOD cTropnT-<0.01 proBNP-7588* ___ 07:18PM BLOOD cTropnT-0.01 ___ 12:45AM BLOOD cTropnT-<0.01 ___ 07:46AM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD ___ 07:10PM BLOOD TSH-1.3 ___ 07:10AM BLOOD 25VitD-39 ___ 06:50AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 06:21AM BLOOD HIV Ab-NEG =============== DISCHARGE LABS: =============== ___ 07:50AM BLOOD WBC-8.6 RBC-3.62* Hgb-10.0* Hct-32.0* MCV-88 MCH-27.6 MCHC-31.3* RDW-17.8* RDWSD-57.1* Plt ___ ___ 07:50AM BLOOD Glucose-101* UreaN-30* Creat-0.9 Na-138 K-5.0 Cl-97 HCO3-28 AnGap-13 ___:50AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.2 ================ IMAGING/STUDIES: ================ ___ CT PELVIS WITHOUT CONTRAST A 2 cm anterior pelvic collection has decreased in size since the reference study from yesterday and is not large enough to contain a drain, and no safe percutaneous approach could be identified. This contains oral contrast, suggestive of a contained perforation likely from the sigmoid colon. 2. A second 3 cm collection at the cul de sac is unchanged in size but is not approachable for percutaneous drainage. ___ TTE The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal dyskinesis of the basal half of the inferolateral wall (clip 50). The remaining segments contract normally (LVEF = 45 %). No intraventriuclar thrrombus is seen. 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 no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. ___ CXR There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. Calcification of the aortic arch is again noted. The bones appear diffusely osteopenic. ___ STRESS EKG No anginal symptoms with uninterpretable ECG in the presence of baseline ECG abnormalities. Normal blood pressure with blunted heart rate response to the dobutamine/Atropine administration. ___ STRESS ECHO The patient received intravenous dobutamine beginning at 15 mcg/kg/min, increasing to 30mcg/kg/min and 45 mcg/kg/min in 3 minute stages plus 1.0 mg atropine. The exercise ECG was uninterpretable due to resting ST-T wave changes (see exercise report for details). There is normal resting blood pressure and normal blood pressure and blunted heart rate response to dobutamine. Resting images were acquired at a heart rate of 68 bpm and a blood pressure of 98/64 mmHg. These demonstrated basal inferolateral akinesis with normal contractility of other segments (LVEF 50-55%). Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated trace aortic regurgitation with no aortic stenosis or significant mitral regurgitation or resting LVOT gradient. At mid-dose dobutamine [30 mcg/kg/min; heart rate 70 bpm, blood pressure 104/60 mmHg), there was appropriate augmentation of all left ventricular segments except no change in basal akinesis. . At peak dobutamine stress [45 mcg/kg/min and 1.0 mg atropine; heart rate 88 bpm, blood pressure 114/70 mmHg), there was appropriate augmentation of systolic function of all segments except no change in basal akinesis. ___ ESOPHAGOGRAM There are no esophageal strictures, ulcers or obstructing masses present. Tertiary contractions are consistent with presbyesophagus. ============== MICROBIOLOGY: ============== ___ BLOOD CULTURE Blood Culture: NO GROWTH ___ STOOL C. difficile DNA amplification assay: Negative for toxigenic C. difficile ___ BLOOD CULTURE Blood Culture ___ URINE URINE CULTURE: < 10,000 CFU/mL ___ 9:12 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: STAPH AUREUS COAG +. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: ___ with background history of stage II colon cancer, status post right hemicolectomy and chemo (___), chronic diarrhea, and recent admission at ___ (___) with complicated diverticulitis with abscess, status post incomplete ___ drainage, who presents as transfer from ___ with abdominal pain and complicated diverticulitis, found to have new abscesses as well as new weakness and poor PO intake thought to be secondary to severe depression, was started on antidepressive medications and appetite stimulants and now s/p PEG tube placement and for malnutrition with improvement in mood and nutritional status. ==================== ACUTE/ACTIVE ISSUES: ==================== # Complicated diverticulitis with abscess Patient presented with weakness and persistent diarrhea from ___, where CT abdomen/pelvis showed multiple intra-abdominal abscesses. On prior admission, there were multiple similar loculated intra-abdominal collections. Plan with colorectal surgery at that time was to delay possible sigmoid resection to allow inflammation to improve. On this admission, patient commenced on ciprofloxacin/metronidazole and planned for ___ guided drainage of these abscesses. However, CT pelvis on ___ showed decrease in the size of the collections, now not amenable to drainage. Discussion was had between surgery, medicine, patient and her daughter on ___, as questions had been raised by daughter/HCP as to whether surgery was within patient's GOC. It was decided to defer surgery to address the ___ medical, nutritional, and psychosocial issues, given that it was unclear if surgical intervention would correct any of the root problems driving her current functional decline. It was also decided at this time to discontinue antibiotics given absence of systemic inflammatory symptoms. # Severe Malnutrition # Weakness/Gait Instability # Weight Loss Patient presented with weakness as her main complaint on presentation to ___. This was in the setting of persistent nausea, and poor PO intake over the previous few weeks. Neurological examination was within normal limits, and remained so throughout admission. TSH 1.3 so not likely to cause weakness. Initially it was felt decreased PO intake due to nausea was likely secondary to persistent intra-abdominal collections. However, patient's nausea spontaneously resolved without final intervention on these abscesses. Despite small improvement in PO intake, she remained uninterested in food and required IVF for periods of relative hypotension. Mirtazapine was added with no effect. Nutrition followed closely and recommended tube feeding, but patient refused same. TPN was felt not to be a safe option, given her indolent infectious complications of diverticulitis, which theoretically may have carried a risk of bacterial translocation. Eventually after discussion with Ethics, patient and HCP eventually a g-tube was placed ___ and tube feeds were successfully initiated with good weight gain and patient cooperation. # Depression # Apathy to care Throughout admission, the patient appeared pleasant and interactive, although deferred all medical decisions to her daughter/HCP, appeared fatalistic about her situation, and disengaged from medical decision making. Through discussion with daughter on ___ regarding decision-making capacity, the decision was made that the patient lacked capacity on ___. She was initiated on methylphenidate as a stimulant per psychiatric recommendation with improvement in mood. She was also continued on fluoxetine and mirtazapine. # T wave inversions # CAD EKG on ___ showed QTc of 431 and new T wave inversions but troponins were negative. A TTE showed normal left ventricular cavity size with focal systolic dysfunction and mitral regurgitation. A dobutamine stress test was done which showed probable prior myocardial infarction without inducible ischemia. The patient was started on ASA 81mg, metoprolol XL 25mg and continued on her home statin. # Acute on chronic diarrhea Patient complaining of diarrhea ___ times daily but has occurred for months. C diff was negative so home loperimide was resumed. The patient had reoccurrence of diarrhea after starting tube feeds, but this also resolved with increasing fiber content of tube feeds and with home loperamide. # Cellulitis After G tube placement there was concern for cellulitis as the site of insertion was erythematous and the patient complained of abdominal pain. There was no purulence or induration, however patient had one recorded fever. She recieved Mupirocin cream and Clindamycin 300mg Q6H for 5d course (___). # Staph Aureus UTI During her hospital course the patient complained of dysuria and UA was done which showed bacteria, WBCs, and was nitrite positive. Cultures grew highly sensitive coag (+) staph aureus. The source of staph aureus was unclear, given this is not a usual pathogen from urinary tract. The patient was started on ceftriaxone (___) then transitioned to Bactrim based on sensitivities to complete 7 day course (___). BCx were negative and no signs of endocarditis or other deep seated infection. # Anemia The patient had an acute drop in H/H on ___. There were no signs of an active bleed and her Hbg remained stable for the remainder of her stay. ================ CHRONIC ISSUES ================ # Small ascites Identified on prior admission CT. A sample was sent for microbiology but not cytology or cell counts/ fluid studies. Ascitic fluid was negative for infection prior admission. # Hyperlipidemia The patient was continued on home statin. # Vitamin deficiency We continued home cyanocobalamine and Vitamin D plus tube-feeds. ===================== TRANSITIONAL ISSUES ===================== [] Given small volume ascites and weight-loss consider ongoing malignancy work up. [] Please monitor improvement in nutritional status after ___ months of tube feeds and optimization of depression regimen. If symptoms have improved can consider discontinuation of PEG. Current tube feed settings: Osmolite 1.5 @75 ml/hr x16 hours (1800 kcal/75 g protein) with 300ml of free water flushes Q4H []Monitor volume status as patient did require intermittent IVF when she had poor PO intake. [] Ensure psychiatry follow up at time of discharge for optimization of medical regimen for depression treatment. [] Pleasure ensure colorectal follow up at time of discharge for further management of known diverticular disease. [] The patient was found to be HBV non immune, please consider vaccination. [] The patient was started on omeprazole when she was initiated on tube feeds for management of GERD symptoms. Consider discontinuing the PPI if symptoms have resolved. [] The patient's QTC was closely monitored because she received frequent Zofran due to nausea. Last QTc 446, please get EKG to reassess QTc prior to giving any QTc prolonging agents. # Code status: DNR/DNI, MOLST signed # Health care proxy/emergency contact: ___ (HCP) ___ PLAN FOR REHAB STAY NOT GREATER THAN 30 DAYS Medications on Admission: 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin ___ mcg PO DAILY 3. FLUoxetine 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. LOPERamide 2 mg PO QID:PRN Diarrhea Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO QID:PRN GERD 4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 5. MethylPHENIDATE (Ritalin) 5 mg PO BID 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Mirtazapine 15 mg PO QHS 8. Omeprazole 40 mg PO DAILY 9. FLUoxetine 30 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Cyanocobalamin ___ mcg PO DAILY 12. LOPERamide 2 mg PO QID:PRN Diarrhea 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ================== PRIMARY DIAGNOSIS: ================= Complicated diverticulitis with abscess Weakness/Poor appetite Depression/Apathy ==================== SECONDARY DIAGNOSES: ==================== Chronic diarrhea Acute Kidney Injury Hyperlipidemia Anxiety Depression Vitamin D Deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY YOU CAME TO THE HOSPITAL You were admitted because you were feeling weak and we were worried about the fluid collections in your belly. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL - We tried to drain the fluid collections in your belly, but they were too small - You received antibiotics for the collections in your belly initially - Our cardiology doctors saw ___ and recommended a scan of your heart, which was overall ok - You were seen by the nutritionists who started supplements to help increase your strength, you received a feeding tube for your nutrition. - The surgeons had a discussion about whether you needed surgery for the fluid collections, but decided it did not need to be done at this time - You were seen by psychiatry who recommended continuing the same medications for your low mood WHAT YOU SHOULD DO WHEN YOU LEAVE THE HOSPITAL - You should take your medications as instructed - You should go to your doctor's appointments as below It was a pleasure taking care of you. Your ___ Healthcare Team MEDICATION CHANGES: New Medicines: Aspirin 81 mg PO/NG DAILY Calcium Carbonate 500 mg PO as needed for upset stomach Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H: as needed for cough MethylPHENIDATE (Ritalin) 5 mg PO/NG BID Metoprolol Succinate XL 25 mg PO DAILY Mirtazapine 15 mg PO/NG QHS Omeprazole 40 mg PO DAILY Changed Medications: FLUoxetine 20 mg PO DAILY changed to 30 mg PO/NG DAILY Followup Instructions: ___
[ "K5720", "E43", "N179", "A419", "R188", "F05", "L03311", "K9422", "N390", "F5089", "I4581", "D649", "J449", "Z538", "F329", "Z66", "R627", "R453", "Y838", "Y92239", "Z85038", "Z6822", "K219", "B9561", "I2510", "R197", "E785", "E559", "F419", "E876", "N7011", "E860", "R05" ]
Allergies: erythromycin base / morphine Chief Complaint: Weakness/Diarrhea Major Surgical or Invasive Procedure: [MASKED]: Failed [MASKED] guided intrabdominal abscess drainage History of Present Illness: [MASKED] year old woman with history of stage II colon cancer s/p right hemicolectomy and chemo ([MASKED]), chronic diarrhea, recent admission at [MASKED] ([MASKED]) with complicated diverticulitis with abscess s/p incomplete [MASKED] drainage, who presents as transfer from [MASKED] with abdominal pain and complicated diverticulitis found to have new abscesses. In recent [MASKED] admission ([MASKED]), she was found to have acute complicated diverticulitis with intra-abdominal fluid collections suspicious for abscesses. [MASKED] drain was placed in pelvic collection, and it was draining frank pus. She was then sent to rehab ([MASKED] in [MASKED] due to her leg weakness. By the end of her rehab stay, she was having a great of difficult walking, as well as diarrhea and a decreased appetite. She then went from her rehab to live with her daughter [MASKED], her HCP, on [MASKED]. She had [MASKED] services there but given her difficulty walking and weakness, her daughter did not feel comfortable caring for her. From her daughter's home, she went to [MASKED] [MASKED] due to her weakness. Per the daughter, she was observed for two days then sent to [MASKED] in [MASKED]. The rehab facility physician was concerned about her nausea, vomiting, poor PO intake, and weakness and sent her to [MASKED] [MASKED] again. Patient initially presented to [MASKED] with reported concern of ongoing left lower quadrant abdominal pain and ongoing diarrhea. However, the patient denies ever endorsing abdominal pain and her HCP confirmed this. She has a complicated colonic history with prior recurrent C. difficile with recent test reportedly negative, prior episode of diverticulitis that was complicated by multiple loculated fluid collections requiring percutaneous drainage. She has a history of colon cancer and is followed by Dr. [MASKED] in the setting of prior partial colonic resection. At [MASKED], she was noted to be hypokalemic and hypomagnesemic which were both repleted and was found to have mild [MASKED]. Patient also found to be somewhat confused, assumed to be metabolic encephalopathy. Patient was covered with Zosyn and Flagyl and transferred to [MASKED] by request by patient as she is followed here by colorectal surgery. In the ED, initial vitals: 97.5 76 154/60 16 96% RA Exam notable for: Somewhat confused. Abdomen soft, non-distended, non-tender Labs notable for: K 3.3, lactate 1.4, WBC 5.7, Imaging notable for: OSH CT Abd/pelvis read: There is an end to side ilio colic anastomosis seen in the anterior abdomen. The residual colon is significantly tortuous. There is extensive diverticulosis. There is some wall thickening in the sigmoid colon. Along the right aspect of the sigmoid colon, adjacent to the uterine fundus and inseparable from the fundus there is a fluid collection with air-fluid level measuring 2.9Ã-2.4Ã-2.1 cm. Additional collection along the posterior aspect the uterus measuring 3.4Ã-2.5Ã-2.4 cm. A large deep pelvic collection is seen along the undersurface of the sigmoid colon, measuring 11.7Ã-8.8Ã-5.0 cm. Some pelvic stranding is seen. Pt given: OSH gave patient IV zosyn and flagyl [MASKED] 04:01 IV Ciprofloxacin 400 mg [MASKED] 09:14 IV MetroNIDAZOLE 500mg [MASKED] 09:14 IVF NS Started 125 mL/hr [MASKED] 10:51 IV Ondansetron 4 mg Colorectal surgery saw the patient and wanted to continue IV zosyn and vancomycin. They want to talk to [MASKED] about drainage of her abscesses. On the floor, the patient says she has been having trouble walking over the last month that has been progressive. She was not able to say if her weakness was secondary to dizziness or decreased strength but thinks it is more decreased strength. She endorsed nausea and vomiting as well as a decreased appetite. She has lost weight in the past few weeks but she is unsure of how much. She has been having [MASKED] episodes of diarrhea daily but says this is normal for her and has been occurring for the past few months. She also has urinary incontinence at baseline for the past few years and wears diapers at home. She endorsed night sweats for the past few years but no fevers, chills, SOB, chest pain, abdominal pain, melena, BRBPR, dysuria, or decreased sensation/tingling in her extremities. Past Medical History: - Stage III colon cancer previously followed by Dr. [MASKED] s/p right hemicolectomy in [MASKED] with adjuvant chemotherapy [MASKED] and leucovorin - GERD - Asthma - Anxiety - Acute diverticulitis with abscess - Acute renal failure - Chronic diarrhea Social History: [MASKED] Family History: No family hx of malignancy Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VITALS: 98.5 PO 158 / 90 65 18 98 ra GENERAL: alert and oriented x 3, no acute distress but tired and chronically ill, hard of hearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, intact sensation to light touch in [MASKED] Lower extremities, 2+ reflexes bilaterally. =============================== DISCHARGE PHYSICAL EXAMINATION: =============================== VS: [MASKED] 0433 Temp: 99.0 PO BP: 125/66 HR: 67 RR: 18 O2 sat: 95% O2 delivery: Ra GENERAL: NAD sitting up in bed NECK: supple CV: RRR, S1 and S2 normal RESP: CTAB, no wheeze/crackles ABD: No abdominal tenderness, no rash, erythema, or purulence around PEG. EXTREMITIES: Warm and well perfused, no lower extremity edema SKIN: No rashes visible NEURO: A/O x3, CNII-XII grossly intact Pertinent Results: =============== ADMISSION LABS: =============== [MASKED] 02:05AM BLOOD WBC-5.7 RBC-4.69# Hgb-12.6# Hct-39.3# MCV-84 MCH-26.9 MCHC-32.1 RDW-15.9* RDWSD-48.4* Plt [MASKED] [MASKED] 02:05AM BLOOD Neuts-45.3 [MASKED] Monos-10.0 Eos-2.8 Baso-1.1* Im [MASKED] AbsNeut-2.59 AbsLymp-2.32 AbsMono-0.57 AbsEos-0.16 AbsBaso-0.06 [MASKED] 02:05AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 02:05AM BLOOD Plt [MASKED] [MASKED] 02:05AM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-137 K-4.3 Cl-95* HCO3-22 AnGap-20* [MASKED] 02:05AM BLOOD ALT-6 AST-32 AlkPhos-44 TotBili-0.5 [MASKED] 07:10PM BLOOD cTropnT-<0.01 [MASKED] 02:05AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 [MASKED] 07:10PM BLOOD TSH-1.3 [MASKED] 02:26AM BLOOD Lactate-1.4 K-3.3 ========================= PERTINENT INTERVAL LABS: ========================= [MASKED] 07:54AM BLOOD cTropnT-<0.01 proBNP-7588* [MASKED] 07:18PM BLOOD cTropnT-0.01 [MASKED] 12:45AM BLOOD cTropnT-<0.01 [MASKED] 07:46AM BLOOD cTropnT-<0.01 [MASKED] 07:30AM BLOOD [MASKED] 07:10PM BLOOD TSH-1.3 [MASKED] 07:10AM BLOOD 25VitD-39 [MASKED] 06:50AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 06:21AM BLOOD HIV Ab-NEG =============== DISCHARGE LABS: =============== [MASKED] 07:50AM BLOOD WBC-8.6 RBC-3.62* Hgb-10.0* Hct-32.0* MCV-88 MCH-27.6 MCHC-31.3* RDW-17.8* RDWSD-57.1* Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-101* UreaN-30* Creat-0.9 Na-138 K-5.0 Cl-97 HCO3-28 AnGap-13 [MASKED]:50AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.2 ================ IMAGING/STUDIES: ================ [MASKED] CT PELVIS WITHOUT CONTRAST A 2 cm anterior pelvic collection has decreased in size since the reference study from yesterday and is not large enough to contain a drain, and no safe percutaneous approach could be identified. This contains oral contrast, suggestive of a contained perforation likely from the sigmoid colon. 2. A second 3 cm collection at the cul de sac is unchanged in size but is not approachable for percutaneous drainage. [MASKED] TTE The left atrial volume index is normal. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal dyskinesis of the basal half of the inferolateral wall (clip 50). The remaining segments contract normally (LVEF = 45 %). No intraventriuclar thrrombus is seen. 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 no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [MASKED] CXR There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. Calcification of the aortic arch is again noted. The bones appear diffusely osteopenic. [MASKED] STRESS EKG No anginal symptoms with uninterpretable ECG in the presence of baseline ECG abnormalities. Normal blood pressure with blunted heart rate response to the dobutamine/Atropine administration. [MASKED] STRESS ECHO The patient received intravenous dobutamine beginning at 15 mcg/kg/min, increasing to 30mcg/kg/min and 45 mcg/kg/min in 3 minute stages plus 1.0 mg atropine. The exercise ECG was uninterpretable due to resting ST-T wave changes (see exercise report for details). There is normal resting blood pressure and normal blood pressure and blunted heart rate response to dobutamine. Resting images were acquired at a heart rate of 68 bpm and a blood pressure of 98/64 mmHg. These demonstrated basal inferolateral akinesis with normal contractility of other segments (LVEF 50-55%). Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated trace aortic regurgitation with no aortic stenosis or significant mitral regurgitation or resting LVOT gradient. At mid-dose dobutamine [30 mcg/kg/min; heart rate 70 bpm, blood pressure 104/60 mmHg), there was appropriate augmentation of all left ventricular segments except no change in basal akinesis. . At peak dobutamine stress [45 mcg/kg/min and 1.0 mg atropine; heart rate 88 bpm, blood pressure 114/70 mmHg), there was appropriate augmentation of systolic function of all segments except no change in basal akinesis. [MASKED] ESOPHAGOGRAM There are no esophageal strictures, ulcers or obstructing masses present. Tertiary contractions are consistent with presbyesophagus. ============== MICROBIOLOGY: ============== [MASKED] BLOOD CULTURE Blood Culture: NO GROWTH [MASKED] STOOL C. difficile DNA amplification assay: Negative for toxigenic C. difficile [MASKED] BLOOD CULTURE Blood Culture [MASKED] URINE URINE CULTURE: < 10,000 CFU/mL [MASKED] 9:12 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: STAPH AUREUS COAG +. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: [MASKED] with background history of stage II colon cancer, status post right hemicolectomy and chemo ([MASKED]), chronic diarrhea, and recent admission at [MASKED] ([MASKED]) with complicated diverticulitis with abscess, status post incomplete [MASKED] drainage, who presents as transfer from [MASKED] with abdominal pain and complicated diverticulitis, found to have new abscesses as well as new weakness and poor PO intake thought to be secondary to severe depression, was started on antidepressive medications and appetite stimulants and now s/p PEG tube placement and for malnutrition with improvement in mood and nutritional status. ==================== ACUTE/ACTIVE ISSUES: ==================== # Complicated diverticulitis with abscess Patient presented with weakness and persistent diarrhea from [MASKED], where CT abdomen/pelvis showed multiple intra-abdominal abscesses. On prior admission, there were multiple similar loculated intra-abdominal collections. Plan with colorectal surgery at that time was to delay possible sigmoid resection to allow inflammation to improve. On this admission, patient commenced on ciprofloxacin/metronidazole and planned for [MASKED] guided drainage of these abscesses. However, CT pelvis on [MASKED] showed decrease in the size of the collections, now not amenable to drainage. Discussion was had between surgery, medicine, patient and her daughter on [MASKED], as questions had been raised by daughter/HCP as to whether surgery was within patient's GOC. It was decided to defer surgery to address the [MASKED] medical, nutritional, and psychosocial issues, given that it was unclear if surgical intervention would correct any of the root problems driving her current functional decline. It was also decided at this time to discontinue antibiotics given absence of systemic inflammatory symptoms. # Severe Malnutrition # Weakness/Gait Instability # Weight Loss Patient presented with weakness as her main complaint on presentation to [MASKED]. This was in the setting of persistent nausea, and poor PO intake over the previous few weeks. Neurological examination was within normal limits, and remained so throughout admission. TSH 1.3 so not likely to cause weakness. Initially it was felt decreased PO intake due to nausea was likely secondary to persistent intra-abdominal collections. However, patient's nausea spontaneously resolved without final intervention on these abscesses. Despite small improvement in PO intake, she remained uninterested in food and required IVF for periods of relative hypotension. Mirtazapine was added with no effect. Nutrition followed closely and recommended tube feeding, but patient refused same. TPN was felt not to be a safe option, given her indolent infectious complications of diverticulitis, which theoretically may have carried a risk of bacterial translocation. Eventually after discussion with Ethics, patient and HCP eventually a g-tube was placed [MASKED] and tube feeds were successfully initiated with good weight gain and patient cooperation. # Depression # Apathy to care Throughout admission, the patient appeared pleasant and interactive, although deferred all medical decisions to her daughter/HCP, appeared fatalistic about her situation, and disengaged from medical decision making. Through discussion with daughter on [MASKED] regarding decision-making capacity, the decision was made that the patient lacked capacity on [MASKED]. She was initiated on methylphenidate as a stimulant per psychiatric recommendation with improvement in mood. She was also continued on fluoxetine and mirtazapine. # T wave inversions # CAD EKG on [MASKED] showed QTc of 431 and new T wave inversions but troponins were negative. A TTE showed normal left ventricular cavity size with focal systolic dysfunction and mitral regurgitation. A dobutamine stress test was done which showed probable prior myocardial infarction without inducible ischemia. The patient was started on ASA 81mg, metoprolol XL 25mg and continued on her home statin. # Acute on chronic diarrhea Patient complaining of diarrhea [MASKED] times daily but has occurred for months. C diff was negative so home loperimide was resumed. The patient had reoccurrence of diarrhea after starting tube feeds, but this also resolved with increasing fiber content of tube feeds and with home loperamide. # Cellulitis After G tube placement there was concern for cellulitis as the site of insertion was erythematous and the patient complained of abdominal pain. There was no purulence or induration, however patient had one recorded fever. She recieved Mupirocin cream and Clindamycin 300mg Q6H for 5d course ([MASKED]). # Staph Aureus UTI During her hospital course the patient complained of dysuria and UA was done which showed bacteria, WBCs, and was nitrite positive. Cultures grew highly sensitive coag (+) staph aureus. The source of staph aureus was unclear, given this is not a usual pathogen from urinary tract. The patient was started on ceftriaxone ([MASKED]) then transitioned to Bactrim based on sensitivities to complete 7 day course ([MASKED]). BCx were negative and no signs of endocarditis or other deep seated infection. # Anemia The patient had an acute drop in H/H on [MASKED]. There were no signs of an active bleed and her Hbg remained stable for the remainder of her stay. ================ CHRONIC ISSUES ================ # Small ascites Identified on prior admission CT. A sample was sent for microbiology but not cytology or cell counts/ fluid studies. Ascitic fluid was negative for infection prior admission. # Hyperlipidemia The patient was continued on home statin. # Vitamin deficiency We continued home cyanocobalamine and Vitamin D plus tube-feeds. ===================== TRANSITIONAL ISSUES ===================== [] Given small volume ascites and weight-loss consider ongoing malignancy work up. [] Please monitor improvement in nutritional status after [MASKED] months of tube feeds and optimization of depression regimen. If symptoms have improved can consider discontinuation of PEG. Current tube feed settings: Osmolite 1.5 @75 ml/hr x16 hours (1800 kcal/75 g protein) with 300ml of free water flushes Q4H []Monitor volume status as patient did require intermittent IVF when she had poor PO intake. [] Ensure psychiatry follow up at time of discharge for optimization of medical regimen for depression treatment. [] Pleasure ensure colorectal follow up at time of discharge for further management of known diverticular disease. [] The patient was found to be HBV non immune, please consider vaccination. [] The patient was started on omeprazole when she was initiated on tube feeds for management of GERD symptoms. Consider discontinuing the PPI if symptoms have resolved. [] The patient's QTC was closely monitored because she received frequent Zofran due to nausea. Last QTc 446, please get EKG to reassess QTc prior to giving any QTc prolonging agents. # Code status: DNR/DNI, MOLST signed # Health care proxy/emergency contact: [MASKED] (HCP) [MASKED] PLAN FOR REHAB STAY NOT GREATER THAN 30 DAYS Medications on Admission: 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin [MASKED] mcg PO DAILY 3. FLUoxetine 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. LOPERamide 2 mg PO QID:PRN Diarrhea Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO QID:PRN GERD 4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough 5. MethylPHENIDATE (Ritalin) 5 mg PO BID 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Mirtazapine 15 mg PO QHS 8. Omeprazole 40 mg PO DAILY 9. FLUoxetine 30 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Cyanocobalamin [MASKED] mcg PO DAILY 12. LOPERamide 2 mg PO QID:PRN Diarrhea 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: ================== PRIMARY DIAGNOSIS: ================= Complicated diverticulitis with abscess Weakness/Poor appetite Depression/Apathy ==================== SECONDARY DIAGNOSES: ==================== Chronic diarrhea Acute Kidney Injury Hyperlipidemia Anxiety Depression Vitamin D Deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], WHY YOU CAME TO THE HOSPITAL You were admitted because you were feeling weak and we were worried about the fluid collections in your belly. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL - We tried to drain the fluid collections in your belly, but they were too small - You received antibiotics for the collections in your belly initially - Our cardiology doctors saw [MASKED] and recommended a scan of your heart, which was overall ok - You were seen by the nutritionists who started supplements to help increase your strength, you received a feeding tube for your nutrition. - The surgeons had a discussion about whether you needed surgery for the fluid collections, but decided it did not need to be done at this time - You were seen by psychiatry who recommended continuing the same medications for your low mood WHAT YOU SHOULD DO WHEN YOU LEAVE THE HOSPITAL - You should take your medications as instructed - You should go to your doctor's appointments as below It was a pleasure taking care of you. Your [MASKED] Healthcare Team MEDICATION CHANGES: New Medicines: Aspirin 81 mg PO/NG DAILY Calcium Carbonate 500 mg PO as needed for upset stomach Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H: as needed for cough MethylPHENIDATE (Ritalin) 5 mg PO/NG BID Metoprolol Succinate XL 25 mg PO DAILY Mirtazapine 15 mg PO/NG QHS Omeprazole 40 mg PO DAILY Changed Medications: FLUoxetine 20 mg PO DAILY changed to 30 mg PO/NG DAILY Followup Instructions: [MASKED]
[]
[ "N179", "N390", "D649", "J449", "F329", "Z66", "K219", "I2510", "E785", "F419" ]
[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "A419: Sepsis, unspecified organism", "R188: Other ascites", "F05: Delirium due to known physiological condition", "L03311: Cellulitis of abdominal wall", "K9422: Gastrostomy infection", "N390: Urinary tract infection, site not specified", "F5089: Other specified eating disorder", "I4581: Long QT syndrome", "D649: Anemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z538: Procedure and treatment not carried out for other reasons", "F329: Major depressive disorder, single episode, unspecified", "Z66: Do not resuscitate", "R627: Adult failure to thrive", "R453: Demoralization and apathy", "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", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "K219: Gastro-esophageal reflux disease without esophagitis", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R197: Diarrhea, unspecified", "E785: Hyperlipidemia, unspecified", "E559: Vitamin D deficiency, unspecified", "F419: Anxiety disorder, unspecified", "E876: Hypokalemia", "N7011: Chronic salpingitis", "E860: Dehydration", "R05: Cough" ]
10,059,192
25,340,376
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: erythromycin base Attending: ___. Chief Complaint: Complicated diverticulitis Major Surgical or Invasive Procedure: Drain placement History of Present Illness: Ms. ___ is a ___ female with the past medical history of stage III colon cancer s/p hemicolectomy and adjuvant chemo in ___, who presents from ___ with complicated diverticulitis. She initially presented to ___ yesterday on ___ with increased weakness, lightheadedness and "feeling sick" with poor appetite over the past 1 week. She denies any f/c/s, abd pain, n/v. She has had intermittent diarrhea (chronic for her), for which she has been taking Imodium. Last BM on ___, no BRBPR or melena. She has also noted an unintentional weight loss of ___ lbs over the last one year and attributes that to "I just don't eat, I don't bother with it". She denies dysphagia, odynophagia, early satiety. Over the past week she reports increased weakness and lightheadedness. She denies urinary complaints. She has not suffered any recent falls, but presented yesterday due to presyncopal symptoms. Of note, she reports a prior severe episode of diverticulitis ___ year ago, requiring antibiotics but no admission per patient. In the ___ to have profound hypokalemia to 2.3. She was given both IV and PO repletion. CXR and head CT were negative for acute processes. She was admitted to the medical service. During her brief admission, she was noted to have diffuse abdominal tenderness, prompting a CT scan of the abdomen which revealed diverticulitis of the sigmoid colon with multiple abscesses. She was started on zosyn, IVF, and kept NPO. Surgery was consulted and recommended transfer to ___ given patient's underlying colon CA history and prior surgery. At ___, due to family concerns of patient being more confused, she had a head CT and MRI which demonstrated no acute changes except for moderate hippocampal atrophy. Currently, she is resting comfortably but frustrated with feeling weak. She reports the ride in the ambulance caused some abdominal discomfort due to the bouncing, but has no abd pain now. No other new symptoms. ROS: Pertinent positives and negatives as noted in the HPI. 10 other systems were reviewed and are negative. Past Medical History: Stage III colon cancer previously followed by Dr. ___ s/p resection with adjuvant chemotherapy ___ and leucovorin. She has not had to see him in some time and cannot recall her last colonoscopy GERD Asthma Anxiety Social History: ___ Family History: Reviewed and found to be not relevant to this illness/ reason for hospitalization. Physical Exam: PHYSICAL EXAM ON ADMISSION VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. MM significantly dry. 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, +fullness over LLQ and suprapubic area, non-tender to palpation, no peritoneal signs. Bowel sounds present. No HSM GU: +suprapubic fullness, no TTP MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. Able to perform ___ and ___ backwards, ___ recall after 5 minutes. +HOH left ear. PSYCH: pleasant, appropriate affect PHYSICAL EXAM on DISCHARGE VITALS: 98.2 151 / 71 52 18 96 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. MMsignificantly dry. CV: Heart regular, no appreciable murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored. GI: Abdomen soft, + subtle fullness over LLQ and suprapubic area, non-tender to palpation, no peritoneal signs. Bowel sounds present. No HSM. Drain in place, CDI, frankly purulent. GU: +mild suprapubic fullness, no TTP MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. Able to perform ___ and ___ backwards, ___ recall after 5 minutes. +HOH left ear. PSYCH: pleasant, appropriate affect Pertinent Results: LABS PRIOR TO DISCHARGE ___ 06:09AM BLOOD WBC-6.3 RBC-3.54* Hgb-9.5* Hct-30.5* MCV-86 MCH-26.8 MCHC-31.1* RDW-13.8 RDWSD-43.9 Plt ___ ___ 06:09AM BLOOD ___ ___ 05:43AM BLOOD Glucose-116* UreaN-9 Creat-1.0 Na-143 K-3.6 Cl-106 HCO3-25 AnGap-12 ___ 09:30PM BLOOD Calcium-8.1* Phos-2.7 Mg-1.7 OTHER LABS Albumin was 2.5 at ___ TSH was 0.68 at ___ ___ U/A notable for positive blood, 3+ leuks, ___ WBCs, 1+ epis Blood cultures NGTD at ___ Urine culture contaminated at ___ Fluid culture, abscess, mixed flora, still pending Fluid culture, ascites, NGTD IMAGING AND OTHER STUDIES CT Abd/Pelvis ___ There is acute sigmoid diverticulitis with multiple loculated fluid collections suggestive of abscesses located within the pelvis. Based on the position of the collections and the number of separate collections, the findings are not amenable to percutaneous drainage. MRI Head ___ 1. No acute abnormality identified. 2. Moderate hippocampal atrophy. 3. Fluid in the left middle ear could indicate otitis media. CXR ___ The lungs are clear. The heart is normal in size. Atherosclerotic changes seen in the thoracic aorta. Mild spondylosis seen in the thoracic spine. Head CT ___ No acute abnormality. ___ guided drain ___ Limited preprocedure CT of the pelvis with contrast demonstrates multiple loculated fluid collections within the pelvis, similar to recent outside CT abdomen and pelvis. The largest rim enhancing collection containing air and measuring approximately 4.2 x 3.2 cm slightly to the right of the midline was targeted for drain placement. Approximately 13 cc of purulent fluid was drained. Additionally there is more free flowing fluid within the bilateral pelvis. Approximately 10 cc of clear yellow ascites was aspirated from the right pelvic free fluid. 1. Successful CT-guided placement of an ___ pigtail catheter into the rim enhancing pelvic collection containing air. Approximately 13 cc of purulent fluid was drained. Samples were sent for microbiology evaluation. As this appeared frankly purulent, sample was not submitted for cytology. 2. Additionally, a sample of loculated right pelvic free fluid was aspirated, and appeared to be simple ascites. This was sent for microbiology. Brief Hospital Course: ___ with prior colon cancer s/p hemicolectomy and chemotherapy (currently ___, GERD, diarrhea and hypokalemia, who presented with weakness/gait instability, weight loss, ___ and was found to have acute complicated diverticulitis with intra-abdominal fluid collections suspicious for abscesses. Now s/p ___ drain placement with frank pus expressed from one of the collections. She was admitted from ___, and treated with IV antibiotics, bowel rest, IVF. She was seen by CRS and ___, and taken for drain placement into the accessible fluid collection. Frank pus was obtained and sent for microbiology. After this procedure her diet was advanced successfully. Cipro/flagyl were transitioned to PO after diet advancement. She had some diarrhea (C diff negative) and this was managed with Imodium. The CRS service recommended discharge with drain management and followup in their clinic in 2 weeks for further treatment planning. # Complicated diverticulitis with abscess: CRS also querying GYN malignancy. She has improved with rehydration, cipro/flagyl, and bowel rest. CRS recommended attempt at ___ guided drainage, which was done yesterday, with frank pus aspirated; drain was placed and is currently in situ. There are unfortunately multiple collections which are loculated and do not communicate with this collection that is currently draining. I have spoken at length with ___ team, and they report that she will likely need OR for sigmoid resection, and that the goal at this point is antibiotics, drainae of drainable collections, and time for inflammation to improve prior to surgery. - CRS would like to see her in 2 weeks in ___ clinic on antibiotics, at which plan for antibiotics, drain, interval imaging, and OR can be finalized - Continue cipro/flagyl until ___ visit - Continue drain + drain management - F/u finalized abscess fluid culture (and ascites culture) - Continue regular diet with supplements # History of chronic diarrhea # Diarrhea here: Worsening diarrhea reported by patient after advancing her diet, likely in setting of advancing diet, antibiotics, known diverticulitis, and chronic diarrhea. C diff sent and negative. - Titrate antidiarrheal medications for control of diarrhea # Weakness # Gait instability: Acute on chronic/slowly progressive by history. Subjective improvement with rehydration, treatment of above infection. Seen by ___, who recommended rehab. # Weight loss, decreased appetite # Moderate malnutrition: Likely due to infection as above. Same query re: malignancy as below. # Social issues: She is having issues with housing, feels like she can't go back to her ALF. Her HCP is an EMT and lives outside of the state. Her daughter is not her HCP but does live somewhat nearby. She met with social work. Her daughter and granddaughter have started to make plans for caring for her in their own homes after discharge from rehab. Ultimately, she would like to move to ___ to be with her granddaughter and great-grandchildren. # ___ # Hypokalemia: On presentation, improved with rehydration. # GERD: Stable. She was not continued on home PPI and had no symptoms, so this medication was discontinued at discharge. # Small ascites identified on CT: Likely sympathetic in setting of complicated diverticulitis. Sample was sent for microbiology but not cytology or cell counts/ fluid studies. - F/u ascites fluid culture # Question of GYN malignancy: In review of imaging, Dr ___ ___ some concern for underlying gynecologic malignancy as source of these collections. Given finding of frank pus, I would suppose the suspicion is now much lower for this. She would require followup imaging to ensure resolution of these collections anyway, and may well end up going to OR, at which point her GYN organs can be reassessed. Notably, she denies vaginal bleeding or discharge. - Could consider pelvic MRI for further characterization of pelvic organs # Question of otitis on imaging: She denies any symptoms of left otitis media (as seen on MRI). She was recently treated and is being treated with ciprofloxacin, which should provide reasonable treatment for any bacterial otitis. # Question of prolonged QT on EKG at ___. Repeat EKG ___ two hours after ciprofloxacin and sertraline showed U waves, QT was WNL. # Hyperlipidemia: Continued on home statin. # Anxiety/depression: Continued on home sertraline. Code status: She was full code here For billing purposes, >30 minutes spent coordinating discharge to rehab. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 20 mg PO DAILY 2. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY 3. Omeprazole 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. calcium carb-mag ox-zinc sulf 333-133-5 mg oral DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. LOPERamide 2 mg PO QID:PRN Diarrhea 3. MetroNIDAZOLE 500 mg PO TID 4. Atorvastatin 40 mg PO QPM 5. Cyanocobalamin ___ mcg PO DAILY 6. FLUoxetine 20 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute diverticulitis with abscess History of colon cancer GERD Acute renal failure Chronic diarrhea Discharge Condition: Tolerating a regular diet without abdominal pain or nausea Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with weakness and weight loss. You were found to have acute diverticulitis with multiple fluid collections/abscesses. You were treated with IV fluids, antibiotics, and bowel rest and you improved. A drain was placed in one of the larger and more accessible fluid collections, which showed pus consistent with an abscess. You were seen by the colorectal surgery service and they recommended antibiotics, drainage, and followup in their clinic in 2 weeks in order to determine a plan, which may include repeat imaging or surgery. You are being discharged to rehab with the drain and with antibiotics. You will need to follow up closely with the colorectal surgery service. They are planning to see you in outpatient clinic in 2 weeks; their number is below. Followup Instructions: ___
[ "K5720", "N179", "E440", "R188", "E861", "Z85038", "Z9221", "K219", "J45909", "F419", "F329", "R197", "R531", "R2689", "Z6824", "E876", "E785" ]
Allergies: erythromycin base Chief Complaint: Complicated diverticulitis Major Surgical or Invasive Procedure: Drain placement History of Present Illness: Ms. [MASKED] is a [MASKED] female with the past medical history of stage III colon cancer s/p hemicolectomy and adjuvant chemo in [MASKED], who presents from [MASKED] with complicated diverticulitis. She initially presented to [MASKED] yesterday on [MASKED] with increased weakness, lightheadedness and "feeling sick" with poor appetite over the past 1 week. She denies any f/c/s, abd pain, n/v. She has had intermittent diarrhea (chronic for her), for which she has been taking Imodium. Last BM on [MASKED], no BRBPR or melena. She has also noted an unintentional weight loss of [MASKED] lbs over the last one year and attributes that to "I just don't eat, I don't bother with it". She denies dysphagia, odynophagia, early satiety. Over the past week she reports increased weakness and lightheadedness. She denies urinary complaints. She has not suffered any recent falls, but presented yesterday due to presyncopal symptoms. Of note, she reports a prior severe episode of diverticulitis [MASKED] year ago, requiring antibiotics but no admission per patient. In the [MASKED] to have profound hypokalemia to 2.3. She was given both IV and PO repletion. CXR and head CT were negative for acute processes. She was admitted to the medical service. During her brief admission, she was noted to have diffuse abdominal tenderness, prompting a CT scan of the abdomen which revealed diverticulitis of the sigmoid colon with multiple abscesses. She was started on zosyn, IVF, and kept NPO. Surgery was consulted and recommended transfer to [MASKED] given patient's underlying colon CA history and prior surgery. At [MASKED], due to family concerns of patient being more confused, she had a head CT and MRI which demonstrated no acute changes except for moderate hippocampal atrophy. Currently, she is resting comfortably but frustrated with feeling weak. She reports the ride in the ambulance caused some abdominal discomfort due to the bouncing, but has no abd pain now. No other new symptoms. ROS: Pertinent positives and negatives as noted in the HPI. 10 other systems were reviewed and are negative. Past Medical History: Stage III colon cancer previously followed by Dr. [MASKED] s/p resection with adjuvant chemotherapy [MASKED] and leucovorin. She has not had to see him in some time and cannot recall her last colonoscopy GERD Asthma Anxiety Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/ reason for hospitalization. Physical Exam: PHYSICAL EXAM ON ADMISSION VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. MM significantly dry. 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, +fullness over LLQ and suprapubic area, non-tender to palpation, no peritoneal signs. Bowel sounds present. No HSM GU: +suprapubic fullness, no TTP MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. Able to perform [MASKED] and [MASKED] backwards, [MASKED] recall after 5 minutes. +HOH left ear. PSYCH: pleasant, appropriate affect PHYSICAL EXAM on DISCHARGE VITALS: 98.2 151 / 71 52 18 96 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. MMsignificantly dry. CV: Heart regular, no appreciable murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored. GI: Abdomen soft, + subtle fullness over LLQ and suprapubic area, non-tender to palpation, no peritoneal signs. Bowel sounds present. No HSM. Drain in place, CDI, frankly purulent. GU: +mild suprapubic fullness, no TTP MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. Able to perform [MASKED] and [MASKED] backwards, [MASKED] recall after 5 minutes. +HOH left ear. PSYCH: pleasant, appropriate affect Pertinent Results: LABS PRIOR TO DISCHARGE [MASKED] 06:09AM BLOOD WBC-6.3 RBC-3.54* Hgb-9.5* Hct-30.5* MCV-86 MCH-26.8 MCHC-31.1* RDW-13.8 RDWSD-43.9 Plt [MASKED] [MASKED] 06:09AM BLOOD [MASKED] [MASKED] 05:43AM BLOOD Glucose-116* UreaN-9 Creat-1.0 Na-143 K-3.6 Cl-106 HCO3-25 AnGap-12 [MASKED] 09:30PM BLOOD Calcium-8.1* Phos-2.7 Mg-1.7 OTHER LABS Albumin was 2.5 at [MASKED] TSH was 0.68 at [MASKED] [MASKED] U/A notable for positive blood, 3+ leuks, [MASKED] WBCs, 1+ epis Blood cultures NGTD at [MASKED] Urine culture contaminated at [MASKED] Fluid culture, abscess, mixed flora, still pending Fluid culture, ascites, NGTD IMAGING AND OTHER STUDIES CT Abd/Pelvis [MASKED] There is acute sigmoid diverticulitis with multiple loculated fluid collections suggestive of abscesses located within the pelvis. Based on the position of the collections and the number of separate collections, the findings are not amenable to percutaneous drainage. MRI Head [MASKED] 1. No acute abnormality identified. 2. Moderate hippocampal atrophy. 3. Fluid in the left middle ear could indicate otitis media. CXR [MASKED] The lungs are clear. The heart is normal in size. Atherosclerotic changes seen in the thoracic aorta. Mild spondylosis seen in the thoracic spine. Head CT [MASKED] No acute abnormality. [MASKED] guided drain [MASKED] Limited preprocedure CT of the pelvis with contrast demonstrates multiple loculated fluid collections within the pelvis, similar to recent outside CT abdomen and pelvis. The largest rim enhancing collection containing air and measuring approximately 4.2 x 3.2 cm slightly to the right of the midline was targeted for drain placement. Approximately 13 cc of purulent fluid was drained. Additionally there is more free flowing fluid within the bilateral pelvis. Approximately 10 cc of clear yellow ascites was aspirated from the right pelvic free fluid. 1. Successful CT-guided placement of an [MASKED] pigtail catheter into the rim enhancing pelvic collection containing air. Approximately 13 cc of purulent fluid was drained. Samples were sent for microbiology evaluation. As this appeared frankly purulent, sample was not submitted for cytology. 2. Additionally, a sample of loculated right pelvic free fluid was aspirated, and appeared to be simple ascites. This was sent for microbiology. Brief Hospital Course: [MASKED] with prior colon cancer s/p hemicolectomy and chemotherapy (currently [MASKED], GERD, diarrhea and hypokalemia, who presented with weakness/gait instability, weight loss, [MASKED] and was found to have acute complicated diverticulitis with intra-abdominal fluid collections suspicious for abscesses. Now s/p [MASKED] drain placement with frank pus expressed from one of the collections. She was admitted from [MASKED], and treated with IV antibiotics, bowel rest, IVF. She was seen by CRS and [MASKED], and taken for drain placement into the accessible fluid collection. Frank pus was obtained and sent for microbiology. After this procedure her diet was advanced successfully. Cipro/flagyl were transitioned to PO after diet advancement. She had some diarrhea (C diff negative) and this was managed with Imodium. The CRS service recommended discharge with drain management and followup in their clinic in 2 weeks for further treatment planning. # Complicated diverticulitis with abscess: CRS also querying GYN malignancy. She has improved with rehydration, cipro/flagyl, and bowel rest. CRS recommended attempt at [MASKED] guided drainage, which was done yesterday, with frank pus aspirated; drain was placed and is currently in situ. There are unfortunately multiple collections which are loculated and do not communicate with this collection that is currently draining. I have spoken at length with [MASKED] team, and they report that she will likely need OR for sigmoid resection, and that the goal at this point is antibiotics, drainae of drainable collections, and time for inflammation to improve prior to surgery. - CRS would like to see her in 2 weeks in [MASKED] clinic on antibiotics, at which plan for antibiotics, drain, interval imaging, and OR can be finalized - Continue cipro/flagyl until [MASKED] visit - Continue drain + drain management - F/u finalized abscess fluid culture (and ascites culture) - Continue regular diet with supplements # History of chronic diarrhea # Diarrhea here: Worsening diarrhea reported by patient after advancing her diet, likely in setting of advancing diet, antibiotics, known diverticulitis, and chronic diarrhea. C diff sent and negative. - Titrate antidiarrheal medications for control of diarrhea # Weakness # Gait instability: Acute on chronic/slowly progressive by history. Subjective improvement with rehydration, treatment of above infection. Seen by [MASKED], who recommended rehab. # Weight loss, decreased appetite # Moderate malnutrition: Likely due to infection as above. Same query re: malignancy as below. # Social issues: She is having issues with housing, feels like she can't go back to her ALF. Her HCP is an EMT and lives outside of the state. Her daughter is not her HCP but does live somewhat nearby. She met with social work. Her daughter and granddaughter have started to make plans for caring for her in their own homes after discharge from rehab. Ultimately, she would like to move to [MASKED] to be with her granddaughter and great-grandchildren. # [MASKED] # Hypokalemia: On presentation, improved with rehydration. # GERD: Stable. She was not continued on home PPI and had no symptoms, so this medication was discontinued at discharge. # Small ascites identified on CT: Likely sympathetic in setting of complicated diverticulitis. Sample was sent for microbiology but not cytology or cell counts/ fluid studies. - F/u ascites fluid culture # Question of GYN malignancy: In review of imaging, Dr [MASKED] [MASKED] some concern for underlying gynecologic malignancy as source of these collections. Given finding of frank pus, I would suppose the suspicion is now much lower for this. She would require followup imaging to ensure resolution of these collections anyway, and may well end up going to OR, at which point her GYN organs can be reassessed. Notably, she denies vaginal bleeding or discharge. - Could consider pelvic MRI for further characterization of pelvic organs # Question of otitis on imaging: She denies any symptoms of left otitis media (as seen on MRI). She was recently treated and is being treated with ciprofloxacin, which should provide reasonable treatment for any bacterial otitis. # Question of prolonged QT on EKG at [MASKED]. Repeat EKG [MASKED] two hours after ciprofloxacin and sertraline showed U waves, QT was WNL. # Hyperlipidemia: Continued on home statin. # Anxiety/depression: Continued on home sertraline. Code status: She was full code here For billing purposes, >30 minutes spent coordinating discharge to rehab. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 20 mg PO DAILY 2. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY 3. Omeprazole 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin [MASKED] mcg PO DAILY 6. calcium carb-mag ox-zinc sulf 333-133-5 mg oral DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. LOPERamide 2 mg PO QID:PRN Diarrhea 3. MetroNIDAZOLE 500 mg PO TID 4. Atorvastatin 40 mg PO QPM 5. Cyanocobalamin [MASKED] mcg PO DAILY 6. FLUoxetine 20 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Acute diverticulitis with abscess History of colon cancer GERD Acute renal failure Chronic diarrhea Discharge Condition: Tolerating a regular diet without abdominal pain or nausea Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with weakness and weight loss. You were found to have acute diverticulitis with multiple fluid collections/abscesses. You were treated with IV fluids, antibiotics, and bowel rest and you improved. A drain was placed in one of the larger and more accessible fluid collections, which showed pus consistent with an abscess. You were seen by the colorectal surgery service and they recommended antibiotics, drainage, and followup in their clinic in 2 weeks in order to determine a plan, which may include repeat imaging or surgery. You are being discharged to rehab with the drain and with antibiotics. You will need to follow up closely with the colorectal surgery service. They are planning to see you in outpatient clinic in 2 weeks; their number is below. Followup Instructions: [MASKED]
[]
[ "N179", "K219", "J45909", "F419", "F329", "E785" ]
[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "N179: Acute kidney failure, unspecified", "E440: Moderate protein-calorie malnutrition", "R188: Other ascites", "E861: Hypovolemia", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z9221: Personal history of antineoplastic chemotherapy", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R197: Diarrhea, unspecified", "R531: Weakness", "R2689: Other abnormalities of gait and mobility", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "E876: Hypokalemia", "E785: Hyperlipidemia, unspecified" ]
10,059,406
23,005,038
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension, fatigue Major Surgical or Invasive Procedure: ___: DIAGNOSTIC LAPAROSCOPY converted to OPEN EXPLORATORY LAPAROTOMY, SMALL BOWEL RESECTION, cecectomy ___: ABDOMINAL WASHOUT, BOWEL RESECTION primary anastomosis History of Present Illness: ___ ___, legally blind, woman with a history of ESRD due to hypertension and DM on dialysis (MWF) and asthma who presented with hypotension, hypoxia and fatique. Patient reported that she has had approximately a month of diarrhea, felt dehydrated. She denied blood in her stool. She then presented today ___ for her scheduled dialysis ___ dialysis) and she felt very weak. She was found to be hypotensive, was not able to receive dialysis, and transferred to ___ for evaluation. In the ED, she was found to be febrile to 101.8. She was also hypoxic to 90% on arrival and was placed on 2L NC. She notes 8 out of 10 epigastric abdominal pain. Denies chest pain. No oxygen at home. No dysuria or hematuria. Denies nausea, vomiting, change in bowel or bladder function, change in vision or hearing, bruising, adenopathy, new rash or lesion. Of note, patient had a recent admission at ___ unsure if it was for suspected GI bleed or her chronic diarrhea. - In the ED, initial vitals were: Temp 101.8, BP: 100/62, HR 80, RR 14, Spo2 90% on RA - Exam was notable for: Abd: Soft, nontender, nondistended Rectal: Guaiac negative. No gross blood. - Labs were notable for: ___ 07:00PM BLOOD WBC: 11.8* RBC: 2.94* Hgb: 7.3* Hct: 25.1* MCV: 85 MCH: 24.8* MCHC: 29.1* RDW: 16.3* RDWSD: 50.8* Plt Ct: 389 ___ 12:47PM BLOOD ___: 14.3* PTT: 25.4 ___: 1.3* ___ 12:47PM BLOOD Glucose: 192* UreaN: 37* Creat: 6.9* Na: 135 K: 4.9 Cl: 89* HCO3: 24 AnGap: 22* ___ 12:47PM BLOOD cTropnT: 0.45* ___ 06:01PM BLOOD cTropnT: 0.42* ___ 12:47PM BLOOD Albumin: 2.7* Calcium: 7.8* Phos: 4.9* Mg: 1.3* ___ 12:57PM BLOOD Type: ___ pO2: 32* pCO2: 45 pH: 7.40 calTCO2: 29 Base XS: 1 Intubat: NOT INTUBATED ___ 12:57PM BLOOD Glucose: 190* Lactate: 2.3* K: 4.2 - Studies were notable for: RUQ US Impression Cholelithiasis without sonographic evidence of acute cholecystitis. CT Abd &Pelvis with contrast 1. Dilated, fluid-filled loops of small bowel with mural edema and mucosal hyperenhancement in the ileum, without a discrete transition point and hypoenhancement of the terminal ileum is concerning for bowel ischemia. 2. Additional focal area of hypoenhancement of the wall of the more proximal distal ileum also worrisome for ischemia. This focal area demonstrates tiny focus of adjacent extraluminal air. It is uncertain of the extraluminal air is intra or extra vascular. No portal venous gas seen elsewhere. 3. The proximal superior mesenteric artery is patent, although heavy calcification distally makes it difficult to assess the lumen. The superior mesenteric vein appears patent 4. Atrophic kidneys, in keeping with end-stage renal disease. 6 mm left inferior pole hyperdense lesion is incompletely characterized. A non urgent renal ultrasound could be considered for follow-up. 5. Possible left Bartholin's gland cyst. CXR Low lung volumes with possible pulmonary vascular congestion. No pleural effusions or pneumothorax. - The patient was given: IVF, Vancomycin 1000mg, cefepime 2g, Magnesium sulfate - ACS were consulted Presentation is not c/w mesenteric ischemia. Possible c/f radiation enteritis. Recommend GI and nephrology consults. Keep NPO, serial abd exams. No acute surgical intervention at this time. - Renal consulted No acute dialytic needs. Plan to do routine dialysis tomorrow once her work-up is more complete On arrival to the floor, she endorsed above hx. Past Medical History: CERVICAL CANCER YEARS AGO- RADIATION THERAPY ___ years ago MENOPAUSE DIABETES MELLITUS HYPERTENSION ASTHMA BLIND SECONDARY TO DM RETINOPATHY DIABETIC NEUROPATHY CHRONIC RENAL FAILURE DIALYSIS VERTIGO CONSTIPATION DYSPEPSIA Social History: ___ Family History: Both her mother and father, as well as her brother had diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Temp: 100.4, BP 136/68, HR 97, RR 18, Sat 98% on 2L NC GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic mummer in RUSB LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, mildly distended, slightly tender in epigastric and LUQ to deep palpation , no rebound or guarding, No organomegaly. EXTREMITIES: No clubbing, cyanosis, ___ edema to ankles. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Discharge physical exam: see death note in chart Pertinent Results: ___ 01:52AM BLOOD WBC-21.9* RBC-2.67* Hgb-7.3* Hct-26.2* MCV-98 MCH-27.3 MCHC-27.9* RDW-23.9* RDWSD-80.8* Plt ___ ___ 01:52AM BLOOD Glucose-150* UreaN-21* Creat-3.2* Na-141 K-5.1 Cl-99 HCO3-25 AnGap-17 CT Head ___: 1. Study limited by artifact. 2. There are hypodensities of the right occipital lobe and left pons, which in the absence of prior imaging may represent age indeterminate infarct, possibly acute to subacute. 3. No intracranial hemorrhage. 4. MR recommended for further characterization. RECOMMENDATION(S): MR ___ for further characterization of hypodensities in right occipital lobe and left pons, which could represent age-indeterminate infarct. CT abd/pelvis on ___: 1. Edematous appearance of the pancreas is concerning for acute pancreatitis. There is peripancreatic and lesser sac fluid which could be a sequela of pancreatitis. Please correlate with pancreatic enzymes. 2. Postsurgical changes from bowel resection. No CT evidence of anastomotic leak, however please note that this cannot be excluded without the use of oral contrast. 3. No bowel obstruction. No pneumatosis or free air. No evidence of bowel ischemia. 4. Ascites. No drainable/peripheral enhancing collections. 5. Consolidative opacity at lung bases (left more than right) could represent aspiration/aspiration pneumonia. Brief Hospital Course: Ms. ___ presented ___ for her scheduled dialysis ___ DaVita dialysis) and noted that she felt very weak and lightheaded. She was found to be hypotensive, was not able to receive dialysis, and transferred to ___ for evaluation. She was initially admitted to the Medicine Service, where she experienced significant GI symptoms, including nausea, vomiting, and diarrhea. An NG Tube was placed, and the patient was kept NPO for treatment of presumed small bowel obstruction. Interval radiologic imaging was concerning for ischemic ileitis, and the patient was evaluated for further surgical management. Ms. ___ was transferred to the Acute Care Surgery Service postoperatively on ___. For full details on the procedure, please refer to the operative note. She was initially left open and in discontinuity. She remained dependent on the ventilator and her blood pressure was supported with pressors. Given her instability, her baseline hemodialysis was held. She ultimately returned to the operating room on ___ for reanastomosis and closure of her laparotomy. Her skin was left open an a wound vac was placed. She returned to the ICU again for further cares. Given her persistent critical illness, she was transitioned to continuous hemodialysis. Her pressor support decreased and ultimately she was started on nasogastric tube feeds. She was able to be extubated to high flow nasal cannula. She had persistently elevated gastric residuals after her tube feeds were advanced. An attempt was made to advance ___ hoff tube to a post pyloric position, at which time she had an episode of emesis and possible aspiration event. Her tachypnea and oxygen requirement increased acutely. Her CRRT ultrafiltration was increased and her respiratory status improved. She continued on CRRT with inability to transition to intermittent HD due to episodic hypotension. Given this, her poor respiratory status, and her inability to clinically progress postoperatively, the decision was made to proceed with further imaging. CT head and torso revealed a subacute infarct in her occipital lobe and new infiltrate in her lungs consistent with a likely pneumonia. Her pneumonia was treated with broad spectrum antibiotics. As a result of her clinical condition and poor neurological status, a family meeting was held to discuss the patients goals of care. Her clinical inability to progress and her poor baseline functional status led the family to proceed with DNR/DNI with plans to proceed to comfort measures only once her family was able to visit her. Family meeting was held between the ICU team, palliative medicine and the surgical team. After a lengthy discussion, the family was in agreement with comfort measures only at 1645, ___. On ___ at 11:16am, was in asystole and unresponsive, and patient was pronounced dead. The surgical team, family, and appropriate administrators were notified. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. melatonin 3 mg oral QHS:PRN 2. Labetalol 200 mg PO Frequency is Unknown 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Calcium Carbonate 500 mg PO Frequency is Unknown 5. Gabapentin 300 mg PO TID 6. 70/30 Unknown Dose 7. NIFEdipine (Extended Release) 90 mg PO DAILY 8. Torsemide 100 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Aspirin 81 mg PO DAILY Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Pronounced dead on ___ at 11:16am Discharge Instructions: n/a Followup Instructions: ___
[ "A419", "N186", "I21A1", "R6521", "I6389", "J9601", "J181", "K55019", "K55029", "K520", "I120", "K56609", "E873", "E870", "J9811", "K8020", "L89312", "Z781", "Z66", "Z515", "E11319", "E1140", "E1122", "E8770", "E1165", "H548", "Z992", "J45909", "R0902", "Z8541", "W881XXA", "Y929", "D631", "Z5331" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypotension, fatigue Major Surgical or Invasive Procedure: [MASKED]: DIAGNOSTIC LAPAROSCOPY converted to OPEN EXPLORATORY LAPAROTOMY, SMALL BOWEL RESECTION, cecectomy [MASKED]: ABDOMINAL WASHOUT, BOWEL RESECTION primary anastomosis History of Present Illness: [MASKED] [MASKED], legally blind, woman with a history of ESRD due to hypertension and DM on dialysis (MWF) and asthma who presented with hypotension, hypoxia and fatique. Patient reported that she has had approximately a month of diarrhea, felt dehydrated. She denied blood in her stool. She then presented today [MASKED] for her scheduled dialysis [MASKED] dialysis) and she felt very weak. She was found to be hypotensive, was not able to receive dialysis, and transferred to [MASKED] for evaluation. In the ED, she was found to be febrile to 101.8. She was also hypoxic to 90% on arrival and was placed on 2L NC. She notes 8 out of 10 epigastric abdominal pain. Denies chest pain. No oxygen at home. No dysuria or hematuria. Denies nausea, vomiting, change in bowel or bladder function, change in vision or hearing, bruising, adenopathy, new rash or lesion. Of note, patient had a recent admission at [MASKED] unsure if it was for suspected GI bleed or her chronic diarrhea. - In the ED, initial vitals were: Temp 101.8, BP: 100/62, HR 80, RR 14, Spo2 90% on RA - Exam was notable for: Abd: Soft, nontender, nondistended Rectal: Guaiac negative. No gross blood. - Labs were notable for: [MASKED] 07:00PM BLOOD WBC: 11.8* RBC: 2.94* Hgb: 7.3* Hct: 25.1* MCV: 85 MCH: 24.8* MCHC: 29.1* RDW: 16.3* RDWSD: 50.8* Plt Ct: 389 [MASKED] 12:47PM BLOOD [MASKED]: 14.3* PTT: 25.4 [MASKED]: 1.3* [MASKED] 12:47PM BLOOD Glucose: 192* UreaN: 37* Creat: 6.9* Na: 135 K: 4.9 Cl: 89* HCO3: 24 AnGap: 22* [MASKED] 12:47PM BLOOD cTropnT: 0.45* [MASKED] 06:01PM BLOOD cTropnT: 0.42* [MASKED] 12:47PM BLOOD Albumin: 2.7* Calcium: 7.8* Phos: 4.9* Mg: 1.3* [MASKED] 12:57PM BLOOD Type: [MASKED] pO2: 32* pCO2: 45 pH: 7.40 calTCO2: 29 Base XS: 1 Intubat: NOT INTUBATED [MASKED] 12:57PM BLOOD Glucose: 190* Lactate: 2.3* K: 4.2 - Studies were notable for: RUQ US Impression Cholelithiasis without sonographic evidence of acute cholecystitis. CT Abd &Pelvis with contrast 1. Dilated, fluid-filled loops of small bowel with mural edema and mucosal hyperenhancement in the ileum, without a discrete transition point and hypoenhancement of the terminal ileum is concerning for bowel ischemia. 2. Additional focal area of hypoenhancement of the wall of the more proximal distal ileum also worrisome for ischemia. This focal area demonstrates tiny focus of adjacent extraluminal air. It is uncertain of the extraluminal air is intra or extra vascular. No portal venous gas seen elsewhere. 3. The proximal superior mesenteric artery is patent, although heavy calcification distally makes it difficult to assess the lumen. The superior mesenteric vein appears patent 4. Atrophic kidneys, in keeping with end-stage renal disease. 6 mm left inferior pole hyperdense lesion is incompletely characterized. A non urgent renal ultrasound could be considered for follow-up. 5. Possible left Bartholin's gland cyst. CXR Low lung volumes with possible pulmonary vascular congestion. No pleural effusions or pneumothorax. - The patient was given: IVF, Vancomycin 1000mg, cefepime 2g, Magnesium sulfate - ACS were consulted Presentation is not c/w mesenteric ischemia. Possible c/f radiation enteritis. Recommend GI and nephrology consults. Keep NPO, serial abd exams. No acute surgical intervention at this time. - Renal consulted No acute dialytic needs. Plan to do routine dialysis tomorrow once her work-up is more complete On arrival to the floor, she endorsed above hx. Past Medical History: CERVICAL CANCER YEARS AGO- RADIATION THERAPY [MASKED] years ago MENOPAUSE DIABETES MELLITUS HYPERTENSION ASTHMA BLIND SECONDARY TO DM RETINOPATHY DIABETIC NEUROPATHY CHRONIC RENAL FAILURE DIALYSIS VERTIGO CONSTIPATION DYSPEPSIA Social History: [MASKED] Family History: Both her mother and father, as well as her brother had diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Temp: 100.4, BP 136/68, HR 97, RR 18, Sat 98% on 2L NC GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic mummer in RUSB LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, mildly distended, slightly tender in epigastric and LUQ to deep palpation , no rebound or guarding, No organomegaly. EXTREMITIES: No clubbing, cyanosis, [MASKED] edema to ankles. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Discharge physical exam: see death note in chart Pertinent Results: [MASKED] 01:52AM BLOOD WBC-21.9* RBC-2.67* Hgb-7.3* Hct-26.2* MCV-98 MCH-27.3 MCHC-27.9* RDW-23.9* RDWSD-80.8* Plt [MASKED] [MASKED] 01:52AM BLOOD Glucose-150* UreaN-21* Creat-3.2* Na-141 K-5.1 Cl-99 HCO3-25 AnGap-17 CT Head [MASKED]: 1. Study limited by artifact. 2. There are hypodensities of the right occipital lobe and left pons, which in the absence of prior imaging may represent age indeterminate infarct, possibly acute to subacute. 3. No intracranial hemorrhage. 4. MR recommended for further characterization. RECOMMENDATION(S): MR [MASKED] for further characterization of hypodensities in right occipital lobe and left pons, which could represent age-indeterminate infarct. CT abd/pelvis on [MASKED]: 1. Edematous appearance of the pancreas is concerning for acute pancreatitis. There is peripancreatic and lesser sac fluid which could be a sequela of pancreatitis. Please correlate with pancreatic enzymes. 2. Postsurgical changes from bowel resection. No CT evidence of anastomotic leak, however please note that this cannot be excluded without the use of oral contrast. 3. No bowel obstruction. No pneumatosis or free air. No evidence of bowel ischemia. 4. Ascites. No drainable/peripheral enhancing collections. 5. Consolidative opacity at lung bases (left more than right) could represent aspiration/aspiration pneumonia. Brief Hospital Course: Ms. [MASKED] presented [MASKED] for her scheduled dialysis [MASKED] DaVita dialysis) and noted that she felt very weak and lightheaded. She was found to be hypotensive, was not able to receive dialysis, and transferred to [MASKED] for evaluation. She was initially admitted to the Medicine Service, where she experienced significant GI symptoms, including nausea, vomiting, and diarrhea. An NG Tube was placed, and the patient was kept NPO for treatment of presumed small bowel obstruction. Interval radiologic imaging was concerning for ischemic ileitis, and the patient was evaluated for further surgical management. Ms. [MASKED] was transferred to the Acute Care Surgery Service postoperatively on [MASKED]. For full details on the procedure, please refer to the operative note. She was initially left open and in discontinuity. She remained dependent on the ventilator and her blood pressure was supported with pressors. Given her instability, her baseline hemodialysis was held. She ultimately returned to the operating room on [MASKED] for reanastomosis and closure of her laparotomy. Her skin was left open an a wound vac was placed. She returned to the ICU again for further cares. Given her persistent critical illness, she was transitioned to continuous hemodialysis. Her pressor support decreased and ultimately she was started on nasogastric tube feeds. She was able to be extubated to high flow nasal cannula. She had persistently elevated gastric residuals after her tube feeds were advanced. An attempt was made to advance [MASKED] hoff tube to a post pyloric position, at which time she had an episode of emesis and possible aspiration event. Her tachypnea and oxygen requirement increased acutely. Her CRRT ultrafiltration was increased and her respiratory status improved. She continued on CRRT with inability to transition to intermittent HD due to episodic hypotension. Given this, her poor respiratory status, and her inability to clinically progress postoperatively, the decision was made to proceed with further imaging. CT head and torso revealed a subacute infarct in her occipital lobe and new infiltrate in her lungs consistent with a likely pneumonia. Her pneumonia was treated with broad spectrum antibiotics. As a result of her clinical condition and poor neurological status, a family meeting was held to discuss the patients goals of care. Her clinical inability to progress and her poor baseline functional status led the family to proceed with DNR/DNI with plans to proceed to comfort measures only once her family was able to visit her. Family meeting was held between the ICU team, palliative medicine and the surgical team. After a lengthy discussion, the family was in agreement with comfort measures only at 1645, [MASKED]. On [MASKED] at 11:16am, was in asystole and unresponsive, and patient was pronounced dead. The surgical team, family, and appropriate administrators were notified. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. melatonin 3 mg oral QHS:PRN 2. Labetalol 200 mg PO Frequency is Unknown 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Calcium Carbonate 500 mg PO Frequency is Unknown 5. Gabapentin 300 mg PO TID 6. 70/30 Unknown Dose 7. NIFEdipine (Extended Release) 90 mg PO DAILY 8. Torsemide 100 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Aspirin 81 mg PO DAILY Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Pronounced dead on [MASKED] at 11:16am Discharge Instructions: n/a Followup Instructions: [MASKED]
[]
[ "J9601", "Z66", "Z515", "E1122", "E1165", "J45909", "Y929" ]
[ "A419: Sepsis, unspecified organism", "N186: End stage renal disease", "I21A1: Myocardial infarction type 2", "R6521: Severe sepsis with septic shock", "I6389: Other cerebral infarction", "J9601: Acute respiratory failure with hypoxia", "J181: Lobar pneumonia, unspecified organism", "K55019: Acute (reversible) ischemia of small intestine, extent unspecified", "K55029: Acute infarction of small intestine, extent unspecified", "K520: Gastroenteritis and colitis due to radiation", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "E873: Alkalosis", "E870: Hyperosmolality and hypernatremia", "J9811: Atelectasis", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "L89312: Pressure ulcer of right buttock, stage 2", "Z781: Physical restraint status", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E8770: Fluid overload, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "H548: Legal blindness, as defined in USA", "Z992: Dependence on renal dialysis", "J45909: Unspecified asthma, uncomplicated", "R0902: Hypoxemia", "Z8541: Personal history of malignant neoplasm of cervix uteri", "W881XXA: Exposure to radioactive isotopes, initial encounter", "Y929: Unspecified place or not applicable", "D631: Anemia in chronic kidney disease", "Z5331: Laparoscopic surgical procedure converted to open procedure" ]
10,059,917
24,017,710
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Erythromycin Base / Keflex Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old female who presents as transfer from OSH with rib fractures. Patient stated that she arrived home last night and was "hurrying to the bathroom" secondary to having taken a laxative and having diarrhea. She then thinks she turned quickly and struck her chest on the counter. She denies head strike or LOC. She denies any fall or syncope. She had chest pain throughout the night and spent the night sitting in a recliner after which she called her family in AM and was brought to ___. There she was found to have multiple left rib fractures (___). Ms. ___ endorses mild pain to the left chest radiating to the back with inspiration. She denies SOB or other constitutional symptoms. She denies HA or other pain besides her left flank with deep inspiration. She has a mild cough with deep inspiration. Of note, patient had a slip and fall in ___ also with multiple left sided rib fractures and evidence of additional old rib fractures on CT scan. She lives at home alone and ambulates independently at baseline. She has a history of osteopenia. Past Medical History: Past Medical History: - Osteopenia - Hypertension - Hyperlipidemia - GERD - Chronic LBP - Depression - Anxiety - Urge incontinence - Allergic rhinitis Past Surgical History: - ___, Hysterectomy for fibroids. - ___, Breast reduction - Tonsillectomy. Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: VS: 98.5 72 192/78 17 98% RA Gen: WA, NAD CV: RRR Pulm: comfortable on RA, some pain with deep inspiration which also elicits cough, normal WOB. TTP of left lateral chest wall Abd: soft, NT/ND Ext: WWP, small skin avulsion over left anterior forearm. Discharge Physical Exam: VS: T: 97.3 BP: 167/74 HR: 60 RR: 17 O2: 98% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l CHEST: tender to palpation over left posterior chest wall c/w rib fracture pain. Symmetric expansion, no lesions ABD: soft, non-distended, non-tender to palpation EXT: LUE abrasion, b/l scattered old abrasions Pertinent Results: IMAGING: ___: CT Head: No acute intracranial abnormality. ___: CT C-spine: 1. No acute fracture or traumatic malalignment. 2. Moderate to severe cervical spondylosis. LABS: ___ 03:10PM GLUCOSE-173* UREA N-24* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 ___ 03:10PM WBC-8.6 RBC-3.61* HGB-11.2 HCT-34.9 MCV-97 MCH-31.0 MCHC-32.1 RDW-14.4 RDWSD-51.2* ___ 03:10PM NEUTS-70.6 LYMPHS-18.0* MONOS-9.0 EOS-1.1 BASOS-1.1* IM ___ AbsNeut-6.04 AbsLymp-1.54 AbsMono-0.77 AbsEos-0.09 AbsBaso-0.09* ___ 03:10PM PLT COUNT-220 ___ 03:10PM ___ PTT-25.5 ___ Brief Hospital Course: Ms. ___ is a ___ year-old female who presented to ___ as a transfer from ___ with left-sided ___ rib fractures after she struck her chest on a counter. The patient was admitted to the Acute Care Surgery Trauma service for pulmonary toilet and pain control. Pain was managed with tramadol and acetaminophen. The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient worked with Physical Therapy and it was recommended she be discharged to rehab to continue her recovery. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, out of bed with asssist, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMLODIPINE - 5mg daily ATORVASTATIN - atorvastatin 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) DIAZEPAM [VALIUM] - Valium 2 mg tablet. 1 Tablet(s) by mouth daily as needed - (Prescribed by Other Provider) (Not Taking as Prescribed) DOXAZOSIN - doxazosin 1 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) DULOXETINE [CYMBALTA] - Cymbalta 30 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Dosage uncertain - (Prescribed by Other Provider) ESCITALOPRAM OXALATE [LEXAPRO] - Lexapro 5 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) ESTRADIOL - estradiol 0.5 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) EZETIMIBE [ZETIA] - Zetia 10 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) FLUTICASONE-SALMETEROL [ADVAIR HFA] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) LISINOPRIL - lisinopril 20 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) NEBIVOLOL [BYSTOLIC] - Dosage uncertain - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - Dosage uncertain - (Prescribed by Other Provider) ASCORBIC ACID (VITAMIN C) [VITAMIN C] - Dosage uncertain - (Prescribed by Other Provider; OTC) (Not Taking as Prescribed) ASPIRIN - aspirin 81 mg tablet,delayed release. Tablet(s) by mouth daily - (Prescribed by Other Provider) CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - Dosage uncertain - (Prescribed by Other Provider) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain - (Prescribed by Other Provider) DIPHENHYDRAMINE HCL [BENADRYL] - Benadryl 25 mg capsule. 1 Capsule(s) by mouth daily @ hs - (Prescribed by Other Provider) (Not Taking as Prescribed) DOCUSATE SODIUM [COLACE] - Dosage uncertain - (Prescribed by Other Provider) L. GASSERI-B. BIFIDUM-B LONGUM ___ COLON HEALTH] - Dosage uncertain - (Prescribed by Other Provider) MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Centrum Silver tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider; ___) (Not Taking as Prescribed) OMEPRAZOLE [PRILOSEC] - Prilosec 20 mg capsule,delayed release. 1 Capsule(s) by mouth daily - (Prescribed by Other Provider; ___) POLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - (Prescribed by Other Provider) PSYLLIUM HUSK [METAMUCIL] - Metamucil 0.52 gram capsule. 6 Capsule(s) by mouth daily - (Prescribed by Other Provider; ___) (Not Taking as Prescribed) SENNOSIDES [SENNA] - Dosage uncertain - (Prescribed by Other Provider) SODIUM CHLORIDE [NASAL] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) VITAMINS A,C,E-ZINC-COPPER [PRESERVISION AREDS] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID Hold for loose stool 3. TraMADol 25 mg PO Q4H:PRN pain Wean as tolerated RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO 3X/WEEK (___) 6. Atorvastatin 20 mg PO DAILY 7. Doxazosin 1 mg PO BID 8. DULoxetine 30 mg PO DAILY 9. Estradiol 0.5 mg PO DAILY 10. Lisinopril 20 mg PO DAILY 11. nebivolol 2.5 mg oral DAILY 12. Omeprazole 40 mg PO QHS 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Left ___ rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with left-sided rib fractures after striking your chest on the counter. You received medication for pain management and your breathing was monitored. You were evaluated by the physical therapist who recommends that you be discharged to rehab to regain your strength. You are now ready to be discharged from the hospital. Please note the following instructions regarding your rib fractures: * Your injury caused multiple left-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 10 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: ___
[ "S2242XA", "W2209XA", "Y92000", "S61512A", "I10", "E785", "J449", "K5900", "M8580", "M545", "G8929", "F329", "F419", "K219", "Z87891", "J309" ]
Allergies: Erythromycin Base / Keflex Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year-old female who presents as transfer from OSH with rib fractures. Patient stated that she arrived home last night and was "hurrying to the bathroom" secondary to having taken a laxative and having diarrhea. She then thinks she turned quickly and struck her chest on the counter. She denies head strike or LOC. She denies any fall or syncope. She had chest pain throughout the night and spent the night sitting in a recliner after which she called her family in AM and was brought to [MASKED]. There she was found to have multiple left rib fractures ([MASKED]). Ms. [MASKED] endorses mild pain to the left chest radiating to the back with inspiration. She denies SOB or other constitutional symptoms. She denies HA or other pain besides her left flank with deep inspiration. She has a mild cough with deep inspiration. Of note, patient had a slip and fall in [MASKED] also with multiple left sided rib fractures and evidence of additional old rib fractures on CT scan. She lives at home alone and ambulates independently at baseline. She has a history of osteopenia. Past Medical History: Past Medical History: - Osteopenia - Hypertension - Hyperlipidemia - GERD - Chronic LBP - Depression - Anxiety - Urge incontinence - Allergic rhinitis Past Surgical History: - [MASKED], Hysterectomy for fibroids. - [MASKED], Breast reduction - Tonsillectomy. Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Physical Exam: VS: 98.5 72 192/78 17 98% RA Gen: WA, NAD CV: RRR Pulm: comfortable on RA, some pain with deep inspiration which also elicits cough, normal WOB. TTP of left lateral chest wall Abd: soft, NT/ND Ext: WWP, small skin avulsion over left anterior forearm. Discharge Physical Exam: VS: T: 97.3 BP: 167/74 HR: 60 RR: 17 O2: 98% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l CHEST: tender to palpation over left posterior chest wall c/w rib fracture pain. Symmetric expansion, no lesions ABD: soft, non-distended, non-tender to palpation EXT: LUE abrasion, b/l scattered old abrasions Pertinent Results: IMAGING: [MASKED]: CT Head: No acute intracranial abnormality. [MASKED]: CT C-spine: 1. No acute fracture or traumatic malalignment. 2. Moderate to severe cervical spondylosis. LABS: [MASKED] 03:10PM GLUCOSE-173* UREA N-24* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [MASKED] 03:10PM WBC-8.6 RBC-3.61* HGB-11.2 HCT-34.9 MCV-97 MCH-31.0 MCHC-32.1 RDW-14.4 RDWSD-51.2* [MASKED] 03:10PM NEUTS-70.6 LYMPHS-18.0* MONOS-9.0 EOS-1.1 BASOS-1.1* IM [MASKED] AbsNeut-6.04 AbsLymp-1.54 AbsMono-0.77 AbsEos-0.09 AbsBaso-0.09* [MASKED] 03:10PM PLT COUNT-220 [MASKED] 03:10PM [MASKED] PTT-25.5 [MASKED] Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old female who presented to [MASKED] as a transfer from [MASKED] with left-sided [MASKED] rib fractures after she struck her chest on a counter. The patient was admitted to the Acute Care Surgery Trauma service for pulmonary toilet and pain control. Pain was managed with tramadol and acetaminophen. The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient worked with Physical Therapy and it was recommended she be discharged to rehab to continue her recovery. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, out of bed with asssist, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMLODIPINE - 5mg daily ATORVASTATIN - atorvastatin 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) DIAZEPAM [VALIUM] - Valium 2 mg tablet. 1 Tablet(s) by mouth daily as needed - (Prescribed by Other Provider) (Not Taking as Prescribed) DOXAZOSIN - doxazosin 1 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) DULOXETINE [CYMBALTA] - Cymbalta 30 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Dosage uncertain - (Prescribed by Other Provider) ESCITALOPRAM OXALATE [LEXAPRO] - Lexapro 5 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) ESTRADIOL - estradiol 0.5 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) EZETIMIBE [ZETIA] - Zetia 10 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) FLUTICASONE-SALMETEROL [ADVAIR HFA] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) LISINOPRIL - lisinopril 20 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) NEBIVOLOL [BYSTOLIC] - Dosage uncertain - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - Dosage uncertain - (Prescribed by Other Provider) ASCORBIC ACID (VITAMIN C) [VITAMIN C] - Dosage uncertain - (Prescribed by Other Provider; OTC) (Not Taking as Prescribed) ASPIRIN - aspirin 81 mg tablet,delayed release. Tablet(s) by mouth daily - (Prescribed by Other Provider) CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - Dosage uncertain - (Prescribed by Other Provider) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain - (Prescribed by Other Provider) DIPHENHYDRAMINE HCL [BENADRYL] - Benadryl 25 mg capsule. 1 Capsule(s) by mouth daily @ hs - (Prescribed by Other Provider) (Not Taking as Prescribed) DOCUSATE SODIUM [COLACE] - Dosage uncertain - (Prescribed by Other Provider) L. GASSERI-B. BIFIDUM-B LONGUM [MASKED] COLON HEALTH] - Dosage uncertain - (Prescribed by Other Provider) MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Centrum Silver tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider; [MASKED]) (Not Taking as Prescribed) OMEPRAZOLE [PRILOSEC] - Prilosec 20 mg capsule,delayed release. 1 Capsule(s) by mouth daily - (Prescribed by Other Provider; [MASKED]) POLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - (Prescribed by Other Provider) PSYLLIUM HUSK [METAMUCIL] - Metamucil 0.52 gram capsule. 6 Capsule(s) by mouth daily - (Prescribed by Other Provider; [MASKED]) (Not Taking as Prescribed) SENNOSIDES [SENNA] - Dosage uncertain - (Prescribed by Other Provider) SODIUM CHLORIDE [NASAL] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) VITAMINS A,C,E-ZINC-COPPER [PRESERVISION AREDS] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID Hold for loose stool 3. TraMADol 25 mg PO Q4H:PRN pain Wean as tolerated RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO 3X/WEEK ([MASKED]) 6. Atorvastatin 20 mg PO DAILY 7. Doxazosin 1 mg PO BID 8. DULoxetine 30 mg PO DAILY 9. Estradiol 0.5 mg PO DAILY 10. Lisinopril 20 mg PO DAILY 11. nebivolol 2.5 mg oral DAILY 12. Omeprazole 40 mg PO QHS 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: -Left [MASKED] rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with left-sided rib fractures after striking your chest on the counter. You received medication for pain management and your breathing was monitored. You were evaluated by the physical therapist who recommends that you be discharged to rehab to regain your strength. You are now ready to be discharged from the hospital. Please note the following instructions regarding your rib fractures: * Your injury caused multiple left-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 10 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal [MASKED] drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: [MASKED]
[]
[ "I10", "E785", "J449", "K5900", "G8929", "F329", "F419", "K219", "Z87891" ]
[ "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "W2209XA: Striking against other stationary object, initial encounter", "Y92000: Kitchen of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "S61512A: Laceration without foreign body of left wrist, initial encounter", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K5900: Constipation, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "M545: Low back pain", "G8929: Other chronic pain", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "J309: Allergic rhinitis, unspecified" ]
10,059,952
26,572,318
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Crestor Attending: ___. Chief Complaint: Dizziness, s/p ICD shock Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in ___ a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in ___ (___, see below for information on settings), on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who awoke lightheaded at 4AM, and sat for ___ min, and his defibrillator fired x3. Reportedly had CP prior to firing (but patient currently notes he didn't have CP, just felt 'unwell'. Upon arrival to ___ reportedly in ___ given Amiodarone, shocked 100 joules. Changed from reported VT to narrow complex AF 125. no sob. En route w/ EMS, recurrent shock converted from AF --> Sinus Rhythm. Patient was discussed with his outpatient general cardiologist while at ___, Dr. ___ recommended the patient be transferred to ___ to see electrophysiology. he did not recommend further antiarrhythmic medications at this time. In the ED, - Initial vitals were: 96 98 147/82 20 100% RA - Exam notable for: Gen: Comfortable, No Acute Distress HEENT: NC/AT. EOMI. Neck: No swelling. Trachea is midline. No JVD Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Bowel sounds present Ext: No edema, cyanosis, or clubbing. Skin: No rashes. No skin breakdown Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. Heme: No petechia. No ecchymosis. - Labs notable for: Chem7: 140/4.8 / 102/20 / ___ < 158 Trop < 0.01 Lactate 2.4 Ca 9.5, Mg 2.1, P 2.5 LFTs WNL CBC WNL INR: 1.2 - Studies notable for: CXR: No acute cardiopulmonary abnormality. EKG: Sinus at 89. Normal axis. Slightly widened QRS at 131. Lateral TWI, similar to prior. - Vitals on transfer: 97.4 84 125/74 12 97% RA Of note, patient had myelogram earlier this month at outside facility, had aspirin and apixaban held for several days On arrival to the CCU, patient feels better. he notes feeling lightheaded quite often, but felt dizzy as though the room was spinning earlier today. No CP, SOB, abd pain. +constipated, no dysuria. Notes he usually wears CPAP but was off it during much of the night. ROS: Otherwise negative Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - + CABG; coronary anatomy unknown - + PERCUTANEOUS CORONARY INTERVENTIONS x4; coronary anatomy unknown; most recently PCI x3 approximately 8 months ago - PACING/ICD: None - Atrial fibrillation on warfarin - Ischemic cardiomyopathy (LVEF 40-45%) 3. OTHER PAST MEDICAL HISTORY: GERD Peripheral neuropathy Chronic serous otitis media Lumbar spinal stenosis status post laminectomy in ___ LFT abdnormalities Squamous cell carcinoma of the skin Status post tonsillectomy Social History: ___ Family History: Mother with "heart disease," died at ___ years old. Brother, ___ years old, with "heart disease." No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 76 132/75 94% RA GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. DISCHARGE PHYSICAL EXAM ========================= VS: 24 HR Data (last updated ___ @ 553) Temp: 97.8 (Tm 97.8), BP: 153/70 (136-153/58-71), HR: 50, RR: 18 (___), O2 sat: 95% (95-96), O2 delivery: RA, Wt: 198.41 lb/90 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. Pertinent Results: ADMISSION LABS ================= ___ 08:05AM BLOOD WBC-8.0 RBC-4.53* Hgb-14.7 Hct-43.0 MCV-95 MCH-32.5* MCHC-34.2 RDW-12.4 RDWSD-43.0 Plt ___ ___ 08:05AM BLOOD Neuts-73.0* Lymphs-14.9* Monos-10.5 Eos-0.6* Baso-0.4 Im ___ AbsNeut-5.84 AbsLymp-1.19* AbsMono-0.84* AbsEos-0.05 AbsBaso-0.03 ___ 08:05AM BLOOD ___ PTT-34.7 ___ ___ 08:05AM BLOOD Glucose-158* UreaN-13 Creat-1.0 Na-140 K-4.8 Cl-102 HCO3-20* AnGap-18 ___ 08:05AM BLOOD ALT-<5 AST-31 AlkPhos-63 TotBili-0.5 ___ 08:05AM BLOOD Albumin-4.3 Calcium-9.5 Phos-2.5* Mg-2.1 ___ 08:05AM BLOOD TSH-3.4 ___ 08:05AM BLOOD T4-8.3 ___ 08:10AM BLOOD Lactate-2.4* Pertinent Labs ================= Imaging ================= ___ TTE 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 moderately increased/dilated cavity. There is mild to moderate regional left ventricular systolic dysfunction with near-akinesis of the basal and mid inferolateral and hypokinesis of the inferior walls (see schematic). The visually estimated left ventricular ejection fraction is 35-40%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets (3) are moderately thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle. Mild to moderate regional systolic dysfunction consistent with coronary artery disease. Aortic sclerosis without frank stenosis, although leaflets do not appear to be opening normally (reduced ejection fraction). Mild mitral and tricuspid regurgitation. Brief Hospital Course: SUMMARY: ===================== ___ year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in ___ a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in ___, on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who is presenting with several episodes of tachycardia, with possible VT vs. afib with rapid rates. ACUTE ISSUES: ============= #Tachycardia #history of VT/Vfib #history of afib Patient with several episodes of tachycardia, with morphologies appearing c/w either VT or afib with RVR and aberrancy when interrogating pacer. Discussing with EP which it may be or if both. Currently stable and in sinus. No recent HF exacerbations and looks euvolemic on exam. No recent illnesses. Amiodarone is not an option given his history of thyroid storm and mexiletine controls his VT but not A fib. After consultation with EP and collaboration with pt's outpatient EP, decision was made for an ablation to be completed after this hospitalization. Medication regimen included mexiletine, metoprolol 100mg bid and home aspirin,statin. Pacemaker settings were changed to the following: VT1 (monitor) increased from 120 -> 141; VT2 therapy zone increased to 180 (from 142) and initial shock increased from 5J to 30J. #CAD s/p CABG/multiple PCIs: Continued home aspirin, statin, beta blocker CHRONIC ISSUES: =============== # Insulin-dependent diabetes mellitus: Held metformin on admission. Restarted on discharge along with home insulin regimen. # Hyperlipidemia: Continued home Lipitor # GERD: Continued home famotidine # Chronic low back pain: Continued gabapentin #Sleep apnea: Continued CPAP Transitional Issues: - Will need close follow up (within ___ weeks) with his cardiologist: ___. MD for further management of tachyarrythmia (Dr. ___ will call the patient for an appointment for ablation) - Patient on Mexilitene: Would get LFTs every six months to follow liver function - Metoprolol tartrate increased to 100mg PO BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 40 mg PO QHS 2. Gabapentin 300 mg PO DAILY pain 3. Losartan Potassium 25 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Apixaban 5 mg PO BID 7. Atorvastatin 40 mg PO QHS 8. Carbidopa-Levodopa (___) 1 TAB PO TID 9. canagliflozin 300 mg oral QHS 10. Levothyroxine Sodium 75 mcg PO DAILY 11. Metoprolol Tartrate 75 mg PO BID 12. Mexiletine 150 mg PO Q8H 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Oxybutynin 5 mg PO QHS 15. rivastigmine tartrate 3 mg oral BID 16. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY 17. FoLIC Acid 0.4 mg PO DAILY 18. coenzyme Q10 100 mg oral DAILY Discharge Medications: 1. Metoprolol Tartrate 100 mg PO BID RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QHS 5. canagliflozin 300 mg oral QHS 6. Carbidopa-Levodopa (___) 1 TAB PO TID 7. coenzyme Q10 100 mg oral DAILY 8. Famotidine 40 mg PO QHS 9. FoLIC Acid 0.4 mg PO DAILY 10. Gabapentin 300 mg PO DAILY pain 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetFORMIN (Glucophage) 500 mg PO BID 14. Mexiletine 150 mg PO Q8H 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Oxybutynin 5 mg PO QHS 17. rivastigmine tartrate 3 mg oral BID 18. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Atrial Fibrillation with rapid ventricular response 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 while you were admitted at ___. Below is some information regarding your hospitalization. Why was I admitted to the hospital? -Your heart was beating at an abnormally fast rate and in a potentially dangerous rhythm. This required close monitoring in the cardiac intensive care unit. What happened while I was in the hospital? -We monitored your heart rate and rhythm very closely to ensure that it was not beating in a dangerous rhythm. -We adjusted your medications to reduce the risk of your heart beating too quickly. -We adjusted your pacemaker to help keep your heart in a safe rhythm. -We worked close with our team of electrophysiologists (heart rhythm specialists) to develop a treatment plan for your heart. You will need a procedure called an ablation which can be performed by your outpatient electrophysiologist Dr. ___. What should I do when I go home? -See your primary care doctor in ___ weeks. -Take all of your medications as prescribed -Seek emergency medical care if notice that your heart is beating at a rapid rate. Followup Instructions: ___
[ "I472", "I255", "Z4502", "I10", "E785", "K219", "I4891", "Z7901", "E1142", "Z85828", "Z87891", "I2510", "Z951", "Z794", "G8929", "G4730" ]
Allergies: Lipitor / Crestor Chief Complaint: Dizziness, s/p ICD shock Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in [MASKED] a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in [MASKED] ([MASKED], see below for information on settings), on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who awoke lightheaded at 4AM, and sat for [MASKED] min, and his defibrillator fired x3. Reportedly had CP prior to firing (but patient currently notes he didn't have CP, just felt 'unwell'. Upon arrival to [MASKED] reportedly in [MASKED] given Amiodarone, shocked 100 joules. Changed from reported VT to narrow complex AF 125. no sob. En route w/ EMS, recurrent shock converted from AF --> Sinus Rhythm. Patient was discussed with his outpatient general cardiologist while at [MASKED], Dr. [MASKED] recommended the patient be transferred to [MASKED] to see electrophysiology. he did not recommend further antiarrhythmic medications at this time. In the ED, - Initial vitals were: 96 98 147/82 20 100% RA - Exam notable for: Gen: Comfortable, No Acute Distress HEENT: NC/AT. EOMI. Neck: No swelling. Trachea is midline. No JVD Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Bowel sounds present Ext: No edema, cyanosis, or clubbing. Skin: No rashes. No skin breakdown Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. Heme: No petechia. No ecchymosis. - Labs notable for: Chem7: 140/4.8 / 102/20 / [MASKED] < 158 Trop < 0.01 Lactate 2.4 Ca 9.5, Mg 2.1, P 2.5 LFTs WNL CBC WNL INR: 1.2 - Studies notable for: CXR: No acute cardiopulmonary abnormality. EKG: Sinus at 89. Normal axis. Slightly widened QRS at 131. Lateral TWI, similar to prior. - Vitals on transfer: 97.4 84 125/74 12 97% RA Of note, patient had myelogram earlier this month at outside facility, had aspirin and apixaban held for several days On arrival to the CCU, patient feels better. he notes feeling lightheaded quite often, but felt dizzy as though the room was spinning earlier today. No CP, SOB, abd pain. +constipated, no dysuria. Notes he usually wears CPAP but was off it during much of the night. ROS: Otherwise negative Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - + CABG; coronary anatomy unknown - + PERCUTANEOUS CORONARY INTERVENTIONS x4; coronary anatomy unknown; most recently PCI x3 approximately 8 months ago - PACING/ICD: None - Atrial fibrillation on warfarin - Ischemic cardiomyopathy (LVEF 40-45%) 3. OTHER PAST MEDICAL HISTORY: GERD Peripheral neuropathy Chronic serous otitis media Lumbar spinal stenosis status post laminectomy in [MASKED] LFT abdnormalities Squamous cell carcinoma of the skin Status post tonsillectomy Social History: [MASKED] Family History: Mother with "heart disease," died at [MASKED] years old. Brother, [MASKED] years old, with "heart disease." No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 76 132/75 94% RA GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. DISCHARGE PHYSICAL EXAM ========================= VS: 24 HR Data (last updated [MASKED] @ 553) Temp: 97.8 (Tm 97.8), BP: 153/70 (136-153/58-71), HR: 50, RR: 18 ([MASKED]), O2 sat: 95% (95-96), O2 delivery: RA, Wt: 198.41 lb/90 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. Pertinent Results: ADMISSION LABS ================= [MASKED] 08:05AM BLOOD WBC-8.0 RBC-4.53* Hgb-14.7 Hct-43.0 MCV-95 MCH-32.5* MCHC-34.2 RDW-12.4 RDWSD-43.0 Plt [MASKED] [MASKED] 08:05AM BLOOD Neuts-73.0* Lymphs-14.9* Monos-10.5 Eos-0.6* Baso-0.4 Im [MASKED] AbsNeut-5.84 AbsLymp-1.19* AbsMono-0.84* AbsEos-0.05 AbsBaso-0.03 [MASKED] 08:05AM BLOOD [MASKED] PTT-34.7 [MASKED] [MASKED] 08:05AM BLOOD Glucose-158* UreaN-13 Creat-1.0 Na-140 K-4.8 Cl-102 HCO3-20* AnGap-18 [MASKED] 08:05AM BLOOD ALT-<5 AST-31 AlkPhos-63 TotBili-0.5 [MASKED] 08:05AM BLOOD Albumin-4.3 Calcium-9.5 Phos-2.5* Mg-2.1 [MASKED] 08:05AM BLOOD TSH-3.4 [MASKED] 08:05AM BLOOD T4-8.3 [MASKED] 08:10AM BLOOD Lactate-2.4* Pertinent Labs ================= Imaging ================= [MASKED] TTE 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 moderately increased/dilated cavity. There is mild to moderate regional left ventricular systolic dysfunction with near-akinesis of the basal and mid inferolateral and hypokinesis of the inferior walls (see schematic). The visually estimated left ventricular ejection fraction is 35-40%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets (3) are moderately thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle. Mild to moderate regional systolic dysfunction consistent with coronary artery disease. Aortic sclerosis without frank stenosis, although leaflets do not appear to be opening normally (reduced ejection fraction). Mild mitral and tricuspid regurgitation. Brief Hospital Course: SUMMARY: ===================== [MASKED] year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in [MASKED] a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in [MASKED], on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who is presenting with several episodes of tachycardia, with possible VT vs. afib with rapid rates. ACUTE ISSUES: ============= #Tachycardia #history of VT/Vfib #history of afib Patient with several episodes of tachycardia, with morphologies appearing c/w either VT or afib with RVR and aberrancy when interrogating pacer. Discussing with EP which it may be or if both. Currently stable and in sinus. No recent HF exacerbations and looks euvolemic on exam. No recent illnesses. Amiodarone is not an option given his history of thyroid storm and mexiletine controls his VT but not A fib. After consultation with EP and collaboration with pt's outpatient EP, decision was made for an ablation to be completed after this hospitalization. Medication regimen included mexiletine, metoprolol 100mg bid and home aspirin,statin. Pacemaker settings were changed to the following: VT1 (monitor) increased from 120 -> 141; VT2 therapy zone increased to 180 (from 142) and initial shock increased from 5J to 30J. #CAD s/p CABG/multiple PCIs: Continued home aspirin, statin, beta blocker CHRONIC ISSUES: =============== # Insulin-dependent diabetes mellitus: Held metformin on admission. Restarted on discharge along with home insulin regimen. # Hyperlipidemia: Continued home Lipitor # GERD: Continued home famotidine # Chronic low back pain: Continued gabapentin #Sleep apnea: Continued CPAP Transitional Issues: - Will need close follow up (within [MASKED] weeks) with his cardiologist: [MASKED]. MD for further management of tachyarrythmia (Dr. [MASKED] will call the patient for an appointment for ablation) - Patient on Mexilitene: Would get LFTs every six months to follow liver function - Metoprolol tartrate increased to 100mg PO BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 40 mg PO QHS 2. Gabapentin 300 mg PO DAILY pain 3. Losartan Potassium 25 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Apixaban 5 mg PO BID 7. Atorvastatin 40 mg PO QHS 8. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 9. canagliflozin 300 mg oral QHS 10. Levothyroxine Sodium 75 mcg PO DAILY 11. Metoprolol Tartrate 75 mg PO BID 12. Mexiletine 150 mg PO Q8H 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Oxybutynin 5 mg PO QHS 15. rivastigmine tartrate 3 mg oral BID 16. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY 17. FoLIC Acid 0.4 mg PO DAILY 18. coenzyme Q10 100 mg oral DAILY Discharge Medications: 1. Metoprolol Tartrate 100 mg PO BID RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QHS 5. canagliflozin 300 mg oral QHS 6. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 7. coenzyme Q10 100 mg oral DAILY 8. Famotidine 40 mg PO QHS 9. FoLIC Acid 0.4 mg PO DAILY 10. Gabapentin 300 mg PO DAILY pain 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetFORMIN (Glucophage) 500 mg PO BID 14. Mexiletine 150 mg PO Q8H 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Oxybutynin 5 mg PO QHS 17. rivastigmine tartrate 3 mg oral BID 18. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Atrial Fibrillation with rapid ventricular response 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 while you were admitted at [MASKED]. Below is some information regarding your hospitalization. Why was I admitted to the hospital? -Your heart was beating at an abnormally fast rate and in a potentially dangerous rhythm. This required close monitoring in the cardiac intensive care unit. What happened while I was in the hospital? -We monitored your heart rate and rhythm very closely to ensure that it was not beating in a dangerous rhythm. -We adjusted your medications to reduce the risk of your heart beating too quickly. -We adjusted your pacemaker to help keep your heart in a safe rhythm. -We worked close with our team of electrophysiologists (heart rhythm specialists) to develop a treatment plan for your heart. You will need a procedure called an ablation which can be performed by your outpatient electrophysiologist Dr. [MASKED]. What should I do when I go home? -See your primary care doctor in [MASKED] weeks. -Take all of your medications as prescribed -Seek emergency medical care if notice that your heart is beating at a rapid rate. Followup Instructions: [MASKED]
[]
[ "I10", "E785", "K219", "I4891", "Z7901", "Z87891", "I2510", "Z951", "Z794", "G8929" ]
[ "I472: Ventricular tachycardia", "I255: Ischemic cardiomyopathy", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z794: Long term (current) use of insulin", "G8929: Other chronic pain", "G4730: Sleep apnea, unspecified" ]
10,060,338
20,455,346
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION ___ 06:25PM BLOOD WBC-8.8 RBC-5.56 Hgb-16.8 Hct-52.3* MCV-94 MCH-30.2 MCHC-32.1 RDW-14.6 RDWSD-49.6* Plt ___ ___ 06:25PM BLOOD Glucose-213* UreaN-11 Creat-0.9 Na-140 K-4.6 Cl-101 HCO3-26 AnGap-13 ___ 06:25PM BLOOD ALT-27 AST-36 AlkPhos-66 TotBili-0.6 DISCHARGE ___ 12:55PM BLOOD WBC-7.2 RBC-5.29 Hgb-16.1 Hct-48.8 MCV-92 MCH-30.4 MCHC-33.0 RDW-14.4 RDWSD-47.9* Plt ___ ___ 12:55PM BLOOD Glucose-175* UreaN-7 Creat-0.8 Na-138 K-4.4 Cl-103 HCO3-23 AnGap-12 ___ 05:30AM BLOOD ALT-23 AST-28 LD(LDH)-160 AlkPhos-53 TotBili-0.4 CT ABD & PELVIS WITH CO - UNSIGNED READ 1. No free intraperitoneal air. 2. While the rectum with collapse, at the wall appears somewhat thickened and mildly hyperemic, proctitis is not excluded.. 3. Patient is status post CBD stent with expected pneumobilia. The pancreas appears normal. 4. Incidentally noted 0.5 cm right lower lobe pulmonary nodule and 0.8 cm right middle lobe nodular opacity, which appear new since ___. A non urgent dedicated CT chest is recommended for full evaluation of the chest. 5. Apparent mild urinary bladder wall thickening may relate to underdistention. Correlate with urinalysis. RECOMMENDATION(S): Nonurgent chest CT Brief Hospital Course: ___ year old male with history of diastolic CHF, paroxysmal atrial fibrillation on apixaban, COPD, Graves' disease s/p thyroidectomy, diabetes type 2, ampullary adenoma s/p transduodenal resection complicated by residual ampullary adenoma with low grade dysplasia status post recent ERCP with radiofrequency ablation and stent placement on ___, admitted ___ with abdominal pain and vomiting thought to be benign post-procedural inflammation, treated conservatively with improvement able to tolerate regular diet, discharged home # Generalized abdominal pain # Ampullary adenoma # Recent ERCP Patient w recent ERCP with radiofrequency ablation and plastic biliary stent placement who represented with worsening abdominal pain. Exam, labs and CT scan without signs of acute intraabdominal or biliary process. Symptoms were suspected to be secondary to post-procedural inflammation following radiofrequency ablation. Patient managed conservatively with NPO and symptom management. Subsequently weaned from antipain/nausea medications and advanced diet without issue. At time of discharge had not received oxycodone or Zofran for > 24 hours. # Chronic diastolic CHF # Paroxysmal atrial fibrillation Held home Lasix while NPO and poor PO intake, restarted at discharge. Continued digoxin, Propranolol, Apixaban. Discharge weight = 111.09 kg. # Hypothyroidism secondary to thyroidectomy Continued Levothyroxine # COPD Continued Breo ellipta, prn albuterol # GERD continue PPI # Diabetes type 2 Prior to admission, had been instructed to newly start insulin at home (lantus 30 units qHS). On this admission, his ___ were well controlled at lantus 15 units. To avoid risk of hypoglycemia while he is recovering from above procedure and symptoms, recommended to patient that he continue lantus 15 units qHS, with understanding that his insulin requirements may increase as he recovers at home. Provided him with safety parameters and instructed him re: when to call his outpatient providers--he was able to verbalize his understanding. Restarted metformin at discharge. Transitional issues - CT abd/pelvis incidentally showed "2. While the rectum is collapsed, the wall appears somewhat thickened and mildly hyperemic, proctitis is not excluded."; patient symptoms resolved as above, not felt to be consistent with proctitis; could consider additional workup if symptoms recur; - CT abd/pelvis incidentally showed "0.5 cm right lower lobe pulmonary nodule and 0.8 cm right middle lobe nodular opacity, which appear new since ___. A non urgent dedicated CT chest is recommended for full evaluation of the chest." - CT abd/pelvis incidentally showed "Apparent mild urinary bladder wall thickening may relate to underdistention. Correlate with urinalysis." > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Breo Ellipta (fluticasone furoate-vilanterol) 100-25 mcg/dose inhalation DAILY 2. Digoxin 0.25 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Furosemide 20 mg PO BID 5. Levothyroxine Sodium 200 mcg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO QPM 8. Omeprazole 40 mg PO BID 9. Rosuvastatin Calcium 40 mg PO QPM 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 11. Propranolol LA 80 mg PO DAILY 12. Glargine 30 Units Bedtime Discharge Medications: 1. Glargine 15 Units Bedtime 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. Apixaban 5 mg PO BID 4. Breo Ellipta (fluticasone furoate-vilanterol) 100-25 mcg/dose inhalation DAILY 5. Digoxin 0.25 mg PO DAILY 6. Furosemide 20 mg PO BID 7. Levothyroxine Sodium 200 mcg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO QPM 10. Omeprazole 40 mg PO BID 11. Propranolol LA 80 mg PO DAILY 12. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: # Generalized abdominal pain # Ampullary adenoma # Recent ERCP # Chronic diastolic CHF # Paroxysmal atrial fibrillation # Hypothyroidism secondary to thyroidectomy # COPD # Diabetes type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___: It was a pleasure caring for you at ___. You were admitted with abdominal pain. A CT scan was reassuring. You were seen by the GI specialists who did your recent endoscopy ("ERCP"). They thought your pain and nausea were likely due to irritation from the procedure that you had. Your symptoms improved and you are now able to be discharged home. Of note: on your CT scan the radiologists noted 2 small abnormal areas ("nodules") in your lung. They are still discussing what kind of additional testing to recommend. I will be in touch with you regarding their final recommendation this coming week. It will be important for you to have your repeat endoscopy ("ERCP") in ___ weeks. Followup Instructions: ___
[ "R1084", "I5032", "I110", "R112", "F17210", "E785", "I480", "E890", "J449", "E119", "I252", "G4733", "K760", "K219", "I2510", "D135", "Z7901", "Z794", "Z98890", "Z9689" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION [MASKED] 06:25PM BLOOD WBC-8.8 RBC-5.56 Hgb-16.8 Hct-52.3* MCV-94 MCH-30.2 MCHC-32.1 RDW-14.6 RDWSD-49.6* Plt [MASKED] [MASKED] 06:25PM BLOOD Glucose-213* UreaN-11 Creat-0.9 Na-140 K-4.6 Cl-101 HCO3-26 AnGap-13 [MASKED] 06:25PM BLOOD ALT-27 AST-36 AlkPhos-66 TotBili-0.6 DISCHARGE [MASKED] 12:55PM BLOOD WBC-7.2 RBC-5.29 Hgb-16.1 Hct-48.8 MCV-92 MCH-30.4 MCHC-33.0 RDW-14.4 RDWSD-47.9* Plt [MASKED] [MASKED] 12:55PM BLOOD Glucose-175* UreaN-7 Creat-0.8 Na-138 K-4.4 Cl-103 HCO3-23 AnGap-12 [MASKED] 05:30AM BLOOD ALT-23 AST-28 LD(LDH)-160 AlkPhos-53 TotBili-0.4 CT ABD & PELVIS WITH CO - UNSIGNED READ 1. No free intraperitoneal air. 2. While the rectum with collapse, at the wall appears somewhat thickened and mildly hyperemic, proctitis is not excluded.. 3. Patient is status post CBD stent with expected pneumobilia. The pancreas appears normal. 4. Incidentally noted 0.5 cm right lower lobe pulmonary nodule and 0.8 cm right middle lobe nodular opacity, which appear new since [MASKED]. A non urgent dedicated CT chest is recommended for full evaluation of the chest. 5. Apparent mild urinary bladder wall thickening may relate to underdistention. Correlate with urinalysis. RECOMMENDATION(S): Nonurgent chest CT Brief Hospital Course: [MASKED] year old male with history of diastolic CHF, paroxysmal atrial fibrillation on apixaban, COPD, Graves' disease s/p thyroidectomy, diabetes type 2, ampullary adenoma s/p transduodenal resection complicated by residual ampullary adenoma with low grade dysplasia status post recent ERCP with radiofrequency ablation and stent placement on [MASKED], admitted [MASKED] with abdominal pain and vomiting thought to be benign post-procedural inflammation, treated conservatively with improvement able to tolerate regular diet, discharged home # Generalized abdominal pain # Ampullary adenoma # Recent ERCP Patient w recent ERCP with radiofrequency ablation and plastic biliary stent placement who represented with worsening abdominal pain. Exam, labs and CT scan without signs of acute intraabdominal or biliary process. Symptoms were suspected to be secondary to post-procedural inflammation following radiofrequency ablation. Patient managed conservatively with NPO and symptom management. Subsequently weaned from antipain/nausea medications and advanced diet without issue. At time of discharge had not received oxycodone or Zofran for > 24 hours. # Chronic diastolic CHF # Paroxysmal atrial fibrillation Held home Lasix while NPO and poor PO intake, restarted at discharge. Continued digoxin, Propranolol, Apixaban. Discharge weight = 111.09 kg. # Hypothyroidism secondary to thyroidectomy Continued Levothyroxine # COPD Continued Breo ellipta, prn albuterol # GERD continue PPI # Diabetes type 2 Prior to admission, had been instructed to newly start insulin at home (lantus 30 units qHS). On this admission, his [MASKED] were well controlled at lantus 15 units. To avoid risk of hypoglycemia while he is recovering from above procedure and symptoms, recommended to patient that he continue lantus 15 units qHS, with understanding that his insulin requirements may increase as he recovers at home. Provided him with safety parameters and instructed him re: when to call his outpatient providers--he was able to verbalize his understanding. Restarted metformin at discharge. Transitional issues - CT abd/pelvis incidentally showed "2. While the rectum is collapsed, the wall appears somewhat thickened and mildly hyperemic, proctitis is not excluded."; patient symptoms resolved as above, not felt to be consistent with proctitis; could consider additional workup if symptoms recur; - CT abd/pelvis incidentally showed "0.5 cm right lower lobe pulmonary nodule and 0.8 cm right middle lobe nodular opacity, which appear new since [MASKED]. A non urgent dedicated CT chest is recommended for full evaluation of the chest." - CT abd/pelvis incidentally showed "Apparent mild urinary bladder wall thickening may relate to underdistention. Correlate with urinalysis." > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Breo Ellipta (fluticasone furoate-vilanterol) 100-25 mcg/dose inhalation DAILY 2. Digoxin 0.25 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Furosemide 20 mg PO BID 5. Levothyroxine Sodium 200 mcg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO QPM 8. Omeprazole 40 mg PO BID 9. Rosuvastatin Calcium 40 mg PO QPM 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 11. Propranolol LA 80 mg PO DAILY 12. Glargine 30 Units Bedtime Discharge Medications: 1. Glargine 15 Units Bedtime 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. Apixaban 5 mg PO BID 4. Breo Ellipta (fluticasone furoate-vilanterol) 100-25 mcg/dose inhalation DAILY 5. Digoxin 0.25 mg PO DAILY 6. Furosemide 20 mg PO BID 7. Levothyroxine Sodium 200 mcg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO QPM 10. Omeprazole 40 mg PO BID 11. Propranolol LA 80 mg PO DAILY 12. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: # Generalized abdominal pain # Ampullary adenoma # Recent ERCP # Chronic diastolic CHF # Paroxysmal atrial fibrillation # Hypothyroidism secondary to thyroidectomy # COPD # Diabetes type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED]: It was a pleasure caring for you at [MASKED]. You were admitted with abdominal pain. A CT scan was reassuring. You were seen by the GI specialists who did your recent endoscopy ("ERCP"). They thought your pain and nausea were likely due to irritation from the procedure that you had. Your symptoms improved and you are now able to be discharged home. Of note: on your CT scan the radiologists noted 2 small abnormal areas ("nodules") in your lung. They are still discussing what kind of additional testing to recommend. I will be in touch with you regarding their final recommendation this coming week. It will be important for you to have your repeat endoscopy ("ERCP") in [MASKED] weeks. Followup Instructions: [MASKED]
[]
[ "I5032", "I110", "F17210", "E785", "I480", "J449", "E119", "I252", "G4733", "K219", "I2510", "Z7901", "Z794" ]
[ "R1084: Generalized abdominal pain", "I5032: Chronic diastolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "R112: Nausea with vomiting, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "I480: Paroxysmal atrial fibrillation", "E890: Postprocedural hypothyroidism", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "I252: Old myocardial infarction", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K760: Fatty (change of) liver, not elsewhere classified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D135: Benign neoplasm of extrahepatic bile ducts", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z98890: Other specified postprocedural states", "Z9689: Presence of other specified functional implants" ]
10,060,338
23,729,229
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ampullary adenoma Major Surgical or Invasive Procedure: ___: 1. Transduodenal resection ampulla of Vater. 2. Open cholecystectomy. History of Present Illness: The patient is a ___ y.o. male with a history of congestive heart failure, history of a myocardial infarction, COPD and recent obstructive jaundice caused by a large obstructing tubulovillous adenoma of the ampulla of Vater. He has been experiencing significant abdominal pain, and was evaluated by Dr. ___ possible surgical resection. Today he presents for elective transduodenal ampullary resection and cholecystectomy. Past Medical History: COPD pAFib MI ___ Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism ___ T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker ___ ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Prior to Discharge: VS: 97.6, 75, 100/64, 18, 94% RA GEN: Pleasant with NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus CV: RRR PULM: Diminished throughout ABD: Obese, soft, non distended. Subcostal incision open to air with steri strips, minimal tenderness along the incision, no erythema, no drainage. EXTR: Warm, no c/c/e Pertinent Results: RECENT LABS: ___ 03:51AM BLOOD WBC-6.9 RBC-4.12* Hgb-12.8* Hct-38.3* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.0 RDWSD-47.0* Plt ___ ___ 04:00AM BLOOD Glucose-114* UreaN-7 Creat-0.8 Na-141 K-4.6 Cl-99 HCO3-28 AnGap-14 ___ 06:50AM BLOOD ALT-23 AST-18 CK(CPK)-578* AlkPhos-46 Amylase-25 TotBili-0.9 ___ 04:00AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 RADIOLOGY: ___ CXR: IMPRESSION: In comparison with study of ___, the the right subclavian PICC line is been removed. There are increasing opacifications at both bases, most likely representing atelectasis. In the appropriate clinical setting, it would be difficult to unequivocally exclude superimposed pneumonia. Cardiac silhouette is within normal limits. Some indistinctness of pulmonary vessels suggests some underlying pulmonary vascular congestion. ___ CXR: IMPRESSION: Mild pulmonary congestion and small bilateral pleural effusions are new. Bibasilar subsegmental atelectasis persist. ___ CXR: IMPRESSION: In comparison with the study of ___, the cardiomediastinal silhouette is stable and there again is mild pulmonary vascular congestion. Increasing streaks of atelectasis bilaterally. Continued blunting of the right costophrenic angle suggests small pleural effusion. ___ UGI: IMPRESSION: No evidence of leak or obstruction. ___ CXR: IMPRESSION: Heart size and mediastinum are stable. Bibasal areas of atelectasis are noted, minimally improved since the prior study. Small right pleural effusion is re-demonstrated. There is no pneumothorax Brief Hospital Course: The patient with newly diagnosed ampullary adenoma was admitted to the ___ Surgical Service for elective surgical resection. On ___, the patient underwent transduodenal resection ampulla of Vater and open cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After procedure patient was extubated and transferred in the PACU, where he remained overnight. Patient was on IV fluid and antibiotics, with Foley catheter, JP drain to bulb, and epidural catheter for pain control. In PACU patient with history of COPD/OSA/current smoker was required high amount of supplemental O2. Patient was started on home nebulizers, IV fluid was turned down to 50 cc/hr, arterial gas and CXR were obtained. Gas was normal, CXR revealed atelectasis and pulmonary vascular congestion, patient was given 10 mg of IV Lasix. His cardiology meds were restarted in IV equivalent. Patient was transferred to the floor in stable condition. On POD 2, patient's epidural fell out, he received PCA for pain control. Later he was started on Ketamine drip secondary to poor pain control. Medicine was consulted to manage patient's comorbidities. Per medicine ECG was obtain, which was stable compare to pre-op, and cardiac enzymes were cycled x 2 and were normal. Repeat CXR revealed atelectasis, pulmonary congestion and bilateral small pulmonary effusions. Patient received 20 mg of Lasix IV for diuresis. Patient's hypotension improved with after epidural was discontinued. On POD 3, IV fluid was discontinued. On POD 4, patient underwent UGI, which was negative for leak or obstruction. Patient's NGT was discontinued. Patient continued to use high flow oxygen overnight. During daytime he was required nasal cannula with ___ O2. Received 20 mg of IV Lasix. On POD 5, patient was started on clear liquid diet, his home medication were restarted, including Lasix. He continue to ambulate and O2 requirement decreased. On POD 6, BP stable, O2 requirement decreased, ambulating, weight stable, Ketamine and Dilaudid PCA were discontinued, started on oral pain medications. Diet was advanced to full liquid and was well tolerated. CXR was obtained and remained stable, patient received additional 20 mg of IV Lasix to continue diuresis. On POD 7, continue to improve, BM and pain well controlled with PO Dilaudid. JP drain was discontinued as output was low. On POD 8, oxygen was weaned off, still required supplemental O2 overnight secoindary to OSA (on BiPAP at home but not using), ___ cleared the patient for home, diet was advanced to soft solids. DM medication were restarted. On POD 9, patient's staples were removed and steri strips were applied. Patient was discharged home in stable condition. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 325 mg PO DAILY 2. Digoxin 0.25 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Potassium Chloride 20 mEq PO DAILY 8. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Nystatin Oral Suspension 5 mL PO QID:PRN oral thrush 12. MetFORMIN (Glucophage) 500 mg PO BID 13. Magnesium Oxide 400 mg PO DAILY 14. coenzyme Q10 100 mg oral Q24H 15. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 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. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*126 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*11 5. Senna 8.6 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath 8. Aspirin 325 mg PO DAILY 9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN 10. coenzyme Q10 100 mg oral Q24H 11. Digoxin 0.25 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Levothyroxine Sodium 175 mcg PO DAILY 14. Magnesium Oxide 400 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Potassium Chloride 20 mEq PO DAILY 18. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 19. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: 1. Tubulovillous adenoma with focal high-grade dysplasia. 2. Chronic cholecystitis. 3. Hypoxia secondary to COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to the surgery service at ___ for surgical resection of your ampullary mass. Your recovery was complicated by hypotension and hypoxia. Your hypotension improved after epidural analgesia was discontinued, and hypoxia improved after diuresis and ambulation. You and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. ___ office at ___ or Office RNs at ___ if you have any questions or concerns. . Please call your doctor or nurse practitioner if you experience 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 is 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. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___
[ "D135", "I5033", "E46", "K8012", "I480", "G723", "K567", "J9811", "J441", "I9581", "I952", "T413X5A", "Y92230", "I110", "G8918", "R0902", "I252", "E890", "E119", "E785", "K760", "G4733", "Z720", "Z6831" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Ampullary adenoma Major Surgical or Invasive Procedure: [MASKED]: 1. Transduodenal resection ampulla of Vater. 2. Open cholecystectomy. History of Present Illness: The patient is a [MASKED] y.o. male with a history of congestive heart failure, history of a myocardial infarction, COPD and recent obstructive jaundice caused by a large obstructing tubulovillous adenoma of the ampulla of Vater. He has been experiencing significant abdominal pain, and was evaluated by Dr. [MASKED] possible surgical resection. Today he presents for elective transduodenal ampullary resection and cholecystectomy. Past Medical History: COPD pAFib MI [MASKED] Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism [MASKED] T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker [MASKED] ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Prior to Discharge: VS: 97.6, 75, 100/64, 18, 94% RA GEN: Pleasant with NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus CV: RRR PULM: Diminished throughout ABD: Obese, soft, non distended. Subcostal incision open to air with steri strips, minimal tenderness along the incision, no erythema, no drainage. EXTR: Warm, no c/c/e Pertinent Results: RECENT LABS: [MASKED] 03:51AM BLOOD WBC-6.9 RBC-4.12* Hgb-12.8* Hct-38.3* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.0 RDWSD-47.0* Plt [MASKED] [MASKED] 04:00AM BLOOD Glucose-114* UreaN-7 Creat-0.8 Na-141 K-4.6 Cl-99 HCO3-28 AnGap-14 [MASKED] 06:50AM BLOOD ALT-23 AST-18 CK(CPK)-578* AlkPhos-46 Amylase-25 TotBili-0.9 [MASKED] 04:00AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 RADIOLOGY: [MASKED] CXR: IMPRESSION: In comparison with study of [MASKED], the the right subclavian PICC line is been removed. There are increasing opacifications at both bases, most likely representing atelectasis. In the appropriate clinical setting, it would be difficult to unequivocally exclude superimposed pneumonia. Cardiac silhouette is within normal limits. Some indistinctness of pulmonary vessels suggests some underlying pulmonary vascular congestion. [MASKED] CXR: IMPRESSION: Mild pulmonary congestion and small bilateral pleural effusions are new. Bibasilar subsegmental atelectasis persist. [MASKED] CXR: IMPRESSION: In comparison with the study of [MASKED], the cardiomediastinal silhouette is stable and there again is mild pulmonary vascular congestion. Increasing streaks of atelectasis bilaterally. Continued blunting of the right costophrenic angle suggests small pleural effusion. [MASKED] UGI: IMPRESSION: No evidence of leak or obstruction. [MASKED] CXR: IMPRESSION: Heart size and mediastinum are stable. Bibasal areas of atelectasis are noted, minimally improved since the prior study. Small right pleural effusion is re-demonstrated. There is no pneumothorax Brief Hospital Course: The patient with newly diagnosed ampullary adenoma was admitted to the [MASKED] Surgical Service for elective surgical resection. On [MASKED], the patient underwent transduodenal resection ampulla of Vater and open cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After procedure patient was extubated and transferred in the PACU, where he remained overnight. Patient was on IV fluid and antibiotics, with Foley catheter, JP drain to bulb, and epidural catheter for pain control. In PACU patient with history of COPD/OSA/current smoker was required high amount of supplemental O2. Patient was started on home nebulizers, IV fluid was turned down to 50 cc/hr, arterial gas and CXR were obtained. Gas was normal, CXR revealed atelectasis and pulmonary vascular congestion, patient was given 10 mg of IV Lasix. His cardiology meds were restarted in IV equivalent. Patient was transferred to the floor in stable condition. On POD 2, patient's epidural fell out, he received PCA for pain control. Later he was started on Ketamine drip secondary to poor pain control. Medicine was consulted to manage patient's comorbidities. Per medicine ECG was obtain, which was stable compare to pre-op, and cardiac enzymes were cycled x 2 and were normal. Repeat CXR revealed atelectasis, pulmonary congestion and bilateral small pulmonary effusions. Patient received 20 mg of Lasix IV for diuresis. Patient's hypotension improved with after epidural was discontinued. On POD 3, IV fluid was discontinued. On POD 4, patient underwent UGI, which was negative for leak or obstruction. Patient's NGT was discontinued. Patient continued to use high flow oxygen overnight. During daytime he was required nasal cannula with [MASKED] O2. Received 20 mg of IV Lasix. On POD 5, patient was started on clear liquid diet, his home medication were restarted, including Lasix. He continue to ambulate and O2 requirement decreased. On POD 6, BP stable, O2 requirement decreased, ambulating, weight stable, Ketamine and Dilaudid PCA were discontinued, started on oral pain medications. Diet was advanced to full liquid and was well tolerated. CXR was obtained and remained stable, patient received additional 20 mg of IV Lasix to continue diuresis. On POD 7, continue to improve, BM and pain well controlled with PO Dilaudid. JP drain was discontinued as output was low. On POD 8, oxygen was weaned off, still required supplemental O2 overnight secoindary to OSA (on BiPAP at home but not using), [MASKED] cleared the patient for home, diet was advanced to soft solids. DM medication were restarted. On POD 9, patient's staples were removed and steri strips were applied. Patient was discharged home in stable condition. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 325 mg PO DAILY 2. Digoxin 0.25 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Potassium Chloride 20 mEq PO DAILY 8. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 9. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Nystatin Oral Suspension 5 mL PO QID:PRN oral thrush 12. MetFORMIN (Glucophage) 500 mg PO BID 13. Magnesium Oxide 400 mg PO DAILY 14. coenzyme Q10 100 mg oral Q24H 15. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 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. HYDROmorphone (Dilaudid) [MASKED] mg PO Q3H:PRN Pain - Severe RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*126 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*11 5. Senna 8.6 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath 8. Aspirin 325 mg PO DAILY 9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN 10. coenzyme Q10 100 mg oral Q24H 11. Digoxin 0.25 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Levothyroxine Sodium 175 mcg PO DAILY 14. Magnesium Oxide 400 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Potassium Chloride 20 mEq PO DAILY 18. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 19. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: 1. Tubulovillous adenoma with focal high-grade dysplasia. 2. Chronic cholecystitis. 3. Hypoxia secondary to COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the surgery service at [MASKED] for surgical resection of your ampullary mass. Your recovery was complicated by hypotension and hypoxia. Your hypotension improved after epidural analgesia was discontinued, and hypoxia improved after diuresis and ambulation. You and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] or Office RNs at [MASKED] if you have any questions or concerns. . Please call your doctor or nurse practitioner if you experience 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 is 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. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]
[]
[ "I480", "Y92230", "I110", "I252", "E119", "E785", "G4733" ]
[ "D135: Benign neoplasm of extrahepatic bile ducts", "I5033: Acute on chronic diastolic (congestive) heart failure", "E46: Unspecified protein-calorie malnutrition", "K8012: Calculus of gallbladder with acute and chronic cholecystitis without obstruction", "I480: Paroxysmal atrial fibrillation", "G723: Periodic paralysis", "K567: Ileus, unspecified", "J9811: Atelectasis", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "I9581: Postprocedural hypotension", "I952: Hypotension due to drugs", "T413X5A: Adverse effect of local anesthetics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I110: Hypertensive heart disease with heart failure", "G8918: Other acute postprocedural pain", "R0902: Hypoxemia", "I252: Old myocardial infarction", "E890: Postprocedural hypothyroidism", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "K760: Fatty (change of) liver, not elsewhere classified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z720: Tobacco use", "Z6831: Body mass index [BMI] 31.0-31.9, adult" ]
10,060,338
25,267,336
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): Mr. ___ is a ___ male with history of pAFib on digoxin, not on A/C, h/o MI ___ coronary vasospasm, ___, COPD, current smoker, Graves' s/p thyroidectomy, OSA not on CPAP, T2DM (A1C 6%), HL, hypokalemic periodic paralysis, admitted to OSH for biliary obstruction and found to have an ampullary mass now s/p stent placement who presents from ___ for evaluation of persistent RUQ pain and inability to tolerate po. OSH Course: ___ He initially presented with acute onset RUQ pain found to have hyperbilirubinemia to 5. He underwent EUS/ERCP at ___ on ___ which showed an ampullary mass, s/p sphincterotomy with biopsies with plastic stent placement. TBili now normal, WBC 7, vital signs stable, lipase normal, but not tolerating diet advancement beyond clear liquids due to persistent RUQ pain. CT A/P performed on ___ was unremarkable without signs of perforation, infection, obstruction or pancreatitis. He has been NPO since ___ with persistent RUQ dull pain and intermittent severe radiating and sharp pain. He is s/p PICC placement and has been receiving TPN at OSH. He has been continued on Cipro/Flagyll since ___. On arrival to the floor he reported continued RUQ pain dull in nature and constant. He endorses nausea but no vomiting. He has had no diarrhea, fevers/chills, dysuria. He states he's had chronic SOB since ___ after he presented with thyroid storm and underwent thyroidectomy. His SOB has been attributed to COPD, exacerbated by active smoking, OSA and dCHF. He denies significant increase in his chronic baseline SOB over the past week. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative Past Medical History: COPD pAFib MI ___ Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism ___ T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker ___ ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM --------------- VITALS: Temp: 98.9 PO BP: 109/65 HR: 60 RR: 18 O2 sat: 93% on RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Obese abdomen softly distended, tender to palpation in upper quadrants R > L. Bowel sounds quiet. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM --------------- 24 HR Data (last updated ___ @ 1531) Temp: 97.8 (Tm 98.5), BP: 104/70 (104-124/65-81), HR: 76 (70-84), RR: 18, O2 sat: 96% (93-98), O2 delivery: Ra, Wt: 244.7 lb/111 kg GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Obese abdomen, + BS, soft, only minimal TTP in RUQ without R/G, negative ___ GU: No suprapubic fullness or tenderness to palpation MSK: Ext warm with no ___ RUE ___ site c/d/I SKIN: No rashes or ulcerations noted NEURO: AOX3, CN II-XII intact, ___ strength all extremities, sensation grossly intact, gait testing deferred PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS ============== ___ 01:41AM BLOOD WBC-7.9 RBC-5.04 Hgb-15.8 Hct-47.0 MCV-93 MCH-31.3 MCHC-33.6 RDW-13.7 RDWSD-46.8* Plt ___ ___ 01:41AM BLOOD ___ PTT-32.5 ___ ___ 01:41AM BLOOD Glucose-113* UreaN-8 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-14 ___ 01:41AM BLOOD ALT-33 AST-23 LD(LDH)-164 AlkPhos-88 Amylase-44 TotBili-0.8 ___ 01:41AM BLOOD Albumin-4.3 Calcium-8.8 Phos-2.7 Mg-2.2 ___ 05:12AM BLOOD TSH-1.5 DISCHARGE LABS ============== ___ 05:57AM BLOOD WBC-7.4 RBC-4.72 Hgb-14.7 Hct-43.3 MCV-92 MCH-31.1 MCHC-33.9 RDW-13.3 RDWSD-45.1 Plt ___ ___ 05:57AM BLOOD Glucose-285* UreaN-17 Creat-0.8 Na-138 K-4.0 Cl-100 HCO3-25 AnGap-13 ___ 06:01AM BLOOD ALT-45* AST-26 AlkPhos-76 TotBili-0.7 ___ 05:57AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.1 Ca ___: 11 (WNL) CEA: 2.3 (WNL) UA: neg blood, neg nit, neg ___, 30 prot, tr ketones, 2 RBCs, 9 WBCs, no bacteria ============================= OSH Labs ___: ALT 32; AST 19; Tbili 0.7; ALP 89 Tptn 7; Albumin 4 138 / 3.6 > 102 / 22 < 8 / 0.8; AGap=14, gluc 183; Ca 8.6 Admission Labs AST/ALT 283/255, Tbili 5 Hepatitis panel negative STUDIES / MICRO =============== CXR (___): Right-sided PICC is seen with tip terminating in the low SVC/cavoatrial junction. No pneumothorax. No dense consolidative opacity. Cardiac silhouette appears within normal limits. EUS ___ Impression: •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 duct: the pancreas duct measured 3 mm in maximum diameter in the head of the pancreas and 2 mm in maximum diameter in the body of the pancreas. •Bile duct: The maximum diameter of the bile duct was 9 mm and had biliary plastic stent in situ which limited the ampullary exam. •The ampulla was visualized endoscopically with both the echoendoscope as well as a duodenoscope. The depth of invasion of the previously identified ampullary mass was difficult to appreciate on ultrasound given artifact from fatty pancreas and biliary stent. There were no appreciable lymph nodes in the ___ region. •Pancreas parenchyma: The parenchyma in the uncinate, head, body and tail of the pancreas was homogenous, and hyperechoic compatible with fatty pancreas. •Otherwise normal upper eus to third part of the duodenum PATHOLOGIC DIAGNOSIS: Gastrointestinal mucosal biopsies: 1. Ampulla mass: - Fragments of adenoma with tubulovillous morphology. 2. Intraductal polyp: - Fragments of adenoma with tubulovillous morphology, see note. Note: No high-grade dysplasia identified in either specimen. CT A/P (OSH) ___ 1. Interval placement of internal biliary stent with associated pneumobilia. No biliary dilatation. No CT evidence for pancreatitis. Brief Hospital Course: Mr. ___ is a ___ male with history of pAFib on digoxin (not on A/C), h/o MI ___ coronary vasospasm, dCHF, COPD, current smoker, Graves' s/p thyroidectomy, OSA not on CPAP, T2DM (A1C 6%), HL, hypokalemic periodic paralysis, admitted to OSH for biliary obstruction and found to have an ampullary mass now s/p stent placement who was transferred from ___ for evaluation of persistent RUQ pain and inability to tolerate POs. Now tolerating regular diet with limited pain. ACUTE/ACTIVE PROBLEMS: # RUQ pain: # Ampullary adenoma: The patient initially presented to ___ with acute RUQ pain and hyperbilirubinemia. He underwent an EUS/ERCP on ___ at ___ (after which he was transferred back to ___) showing an ampullary mass. Sphincterotomy was performed with biopsies (c/w adenoma) and biliary plastic stent placement. Cholestatic LFTs improved, but he was unable to tolerate a diet at ___ secondary to post-prandial pain. CT A/P showed interval placement of internal biliary stent with associated pneumobilia but no biliary dilation or evidence of pancreatitis. He was treated with cipro/flagyl (initiated ___ and was started on TPN via a RUE PICC at ___ prior to being transferred back to ___ for further evaluation. On arrival, CBC, LFTs, lipase were all WNL. Given his imaging and absence of fever/leukocytosis, cholangitis and cholecystitis were thought unlikely and antibiotics were discontinued (s/p 7d course). His pain was controlled with tylenol and very intermittent oxycodone. He was evaluated by the ___ and ___ surgery services. His ampullary mass was not thought to explain his pain in the absence of LFT abnormalities, and he was scheduled for outpatient surgical f/u with Dr. ___ on ___ at 8am to discuss possible, non-urgent surgical resection. Repeat ERCP was deferred. He was continued on TPN, weaned as his diet was advanced with resolution of his pain. At the time of discharge, he had been tolerating a regular diet for >24h with only minimal RUQ pain (1 out of 10, not associated with food) and no N/V. CEA and CA ___ were sent, both WNL. He will f/u with Dr. ___ as above and with his primary care doctor on ___. # Severe malnutrition: Severe malnutrition in the setting of acute illness, as evidenced by 6% weight loss in ~2 weeks & <50% energy intake compared to estimated energy needs for >5days. He was continued on TPN, initiated at ___. His diet was advanced, and he was tolerating a regular diet to meet his caloric needs at discharge. TPN was weaned and discontinued on ___. # Hyperglycemia: # T2DM: Hx of T2DM, on metformin and glipizide at home. Hperglycemic in house, likely in the setting of TPN. Home anti-hyperglycemics were held and an insulin sliding scale was initiated. In addition, insulin was added to TPN. Glipizide and metformin were reinitiated on discharge. CHRONIC/STABLE PROBLEMS: # COPD: Home Breo-Ellipta was replaced with Advair (given formulary issues), with albuterol PRN. Home regimen continued at discharge. # HFpEF: Appeared euvolemic. Home Lasix PRN was held in house and continued at discharge. Weight at discharge 111kg. # OSA: Has previously declined CPAP. No evidence of desaturations while hospitalized. Deferred further discussions to outpatient providers. # Hypothyroidism: TSH WNL. Continued home thyroid replacement. # pAF: Continued digoxin and metoprolol. Patient was not on anticoagulation. Deferred discussion about initiation of anticoagulation to PCP. # Nicotine dependence: Continued nicotine patches, prescribed on discharge. # Hypokalemic periodic paralysis: K was WNL without episodes. # HLD: Continued home statin. ** TRANSITIONAL ** [ ] f/u with Dr. ___ on ___ at 8 am to discuss ampullary mass resection [ ] will need repeat ERCP in 5 weeks to remove biliary stent [ ] f/u A1c (hyperglycemic in house, likely TPN) [ ] discuss anticoagulation for pAF [ ] discuss CPAP for OSA Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 175 mcg PO DAILY 2. GlipiZIDE XL 5 mg PO DAILY 3. albuterol sulfate 108 mcg inhalation QID:PRN 4. Aspirin EC 81 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Digoxin 0.25 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO QPM 8. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation BID 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Klor-Con M20 (potassium chloride) 30 mEq oral DAILY 11. Furosemide 20 mg PO DAILY PRN edema 12. Propranolol 10 mg PO TID:PRN palpitations Discharge Medications: 1. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour apply one patch daily Disp #*14 Patch Refills:*0 2. albuterol sulfate 108 mcg inhalation QID:PRN 3. Aspirin EC 81 mg PO DAILY 4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation BID 5. Digoxin 0.25 mg PO DAILY 6. Furosemide 20 mg PO DAILY PRN edema 7. GlipiZIDE XL 5 mg PO DAILY 8. Klor-Con M20 (potassium chloride) 30 mEq oral DAILY 9. Levothyroxine Sodium 175 mcg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Propranolol 10 mg PO TID:PRN palpitations 13. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Ampullary mass Biliary obstruction Post-prandial pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were transferred from ___ for persistent abdominal pain after eating. You were continued on TPN, and your pain gradually improved with bowel rest. At the time of discharge, you were eating a regular diet without significant pain. Please follow up with Dr. ___ on ___ to discuss resection of the ampullary mass that was discovered. In addition, you will need a repeat ERCP in about 5 weeks to remove the plastic stent that was placed on ___. The ERCP group should call you with an appointment. Please follow up with your primary care doctor to discuss your other medical issues. We advise you to quit smoking and are providing you with a nicotine patch prescription on discharge. With best wishes, ___ Medicine Followup Instructions: ___
[ "R1011", "E43", "I110", "I5032", "E1165", "D135", "I480", "G723", "E890", "F17210", "J449", "G4733", "Z9689", "I252", "E785" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): Mr. [MASKED] is a [MASKED] male with history of pAFib on digoxin, not on A/C, h/o MI [MASKED] coronary vasospasm, [MASKED], COPD, current smoker, Graves' s/p thyroidectomy, OSA not on CPAP, T2DM (A1C 6%), HL, hypokalemic periodic paralysis, admitted to OSH for biliary obstruction and found to have an ampullary mass now s/p stent placement who presents from [MASKED] for evaluation of persistent RUQ pain and inability to tolerate po. OSH Course: [MASKED] He initially presented with acute onset RUQ pain found to have hyperbilirubinemia to 5. He underwent EUS/ERCP at [MASKED] on [MASKED] which showed an ampullary mass, s/p sphincterotomy with biopsies with plastic stent placement. TBili now normal, WBC 7, vital signs stable, lipase normal, but not tolerating diet advancement beyond clear liquids due to persistent RUQ pain. CT A/P performed on [MASKED] was unremarkable without signs of perforation, infection, obstruction or pancreatitis. He has been NPO since [MASKED] with persistent RUQ dull pain and intermittent severe radiating and sharp pain. He is s/p PICC placement and has been receiving TPN at OSH. He has been continued on Cipro/Flagyll since [MASKED]. On arrival to the floor he reported continued RUQ pain dull in nature and constant. He endorses nausea but no vomiting. He has had no diarrhea, fevers/chills, dysuria. He states he's had chronic SOB since [MASKED] after he presented with thyroid storm and underwent thyroidectomy. His SOB has been attributed to COPD, exacerbated by active smoking, OSA and dCHF. He denies significant increase in his chronic baseline SOB over the past week. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative Past Medical History: COPD pAFib MI [MASKED] Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism [MASKED] T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker [MASKED] ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM --------------- VITALS: Temp: 98.9 PO BP: 109/65 HR: 60 RR: 18 O2 sat: 93% on RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Obese abdomen softly distended, tender to palpation in upper quadrants R > L. Bowel sounds quiet. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM --------------- 24 HR Data (last updated [MASKED] @ 1531) Temp: 97.8 (Tm 98.5), BP: 104/70 (104-124/65-81), HR: 76 (70-84), RR: 18, O2 sat: 96% (93-98), O2 delivery: Ra, Wt: 244.7 lb/111 kg GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Obese abdomen, + BS, soft, only minimal TTP in RUQ without R/G, negative [MASKED] GU: No suprapubic fullness or tenderness to palpation MSK: Ext warm with no [MASKED] RUE [MASKED] site c/d/I SKIN: No rashes or ulcerations noted NEURO: AOX3, CN II-XII intact, [MASKED] strength all extremities, sensation grossly intact, gait testing deferred PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS ============== [MASKED] 01:41AM BLOOD WBC-7.9 RBC-5.04 Hgb-15.8 Hct-47.0 MCV-93 MCH-31.3 MCHC-33.6 RDW-13.7 RDWSD-46.8* Plt [MASKED] [MASKED] 01:41AM BLOOD [MASKED] PTT-32.5 [MASKED] [MASKED] 01:41AM BLOOD Glucose-113* UreaN-8 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-14 [MASKED] 01:41AM BLOOD ALT-33 AST-23 LD(LDH)-164 AlkPhos-88 Amylase-44 TotBili-0.8 [MASKED] 01:41AM BLOOD Albumin-4.3 Calcium-8.8 Phos-2.7 Mg-2.2 [MASKED] 05:12AM BLOOD TSH-1.5 DISCHARGE LABS ============== [MASKED] 05:57AM BLOOD WBC-7.4 RBC-4.72 Hgb-14.7 Hct-43.3 MCV-92 MCH-31.1 MCHC-33.9 RDW-13.3 RDWSD-45.1 Plt [MASKED] [MASKED] 05:57AM BLOOD Glucose-285* UreaN-17 Creat-0.8 Na-138 K-4.0 Cl-100 HCO3-25 AnGap-13 [MASKED] 06:01AM BLOOD ALT-45* AST-26 AlkPhos-76 TotBili-0.7 [MASKED] 05:57AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.1 Ca [MASKED]: 11 (WNL) CEA: 2.3 (WNL) UA: neg blood, neg nit, neg [MASKED], 30 prot, tr ketones, 2 RBCs, 9 WBCs, no bacteria ============================= OSH Labs [MASKED]: ALT 32; AST 19; Tbili 0.7; ALP 89 Tptn 7; Albumin 4 138 / 3.6 > 102 / 22 < 8 / 0.8; AGap=14, gluc 183; Ca 8.6 Admission Labs AST/ALT 283/255, Tbili 5 Hepatitis panel negative STUDIES / MICRO =============== CXR ([MASKED]): Right-sided PICC is seen with tip terminating in the low SVC/cavoatrial junction. No pneumothorax. No dense consolidative opacity. Cardiac silhouette appears within normal limits. EUS [MASKED] Impression: •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 duct: the pancreas duct measured 3 mm in maximum diameter in the head of the pancreas and 2 mm in maximum diameter in the body of the pancreas. •Bile duct: The maximum diameter of the bile duct was 9 mm and had biliary plastic stent in situ which limited the ampullary exam. •The ampulla was visualized endoscopically with both the echoendoscope as well as a duodenoscope. The depth of invasion of the previously identified ampullary mass was difficult to appreciate on ultrasound given artifact from fatty pancreas and biliary stent. There were no appreciable lymph nodes in the [MASKED] region. •Pancreas parenchyma: The parenchyma in the uncinate, head, body and tail of the pancreas was homogenous, and hyperechoic compatible with fatty pancreas. •Otherwise normal upper eus to third part of the duodenum PATHOLOGIC DIAGNOSIS: Gastrointestinal mucosal biopsies: 1. Ampulla mass: - Fragments of adenoma with tubulovillous morphology. 2. Intraductal polyp: - Fragments of adenoma with tubulovillous morphology, see note. Note: No high-grade dysplasia identified in either specimen. CT A/P (OSH) [MASKED] 1. Interval placement of internal biliary stent with associated pneumobilia. No biliary dilatation. No CT evidence for pancreatitis. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of pAFib on digoxin (not on A/C), h/o MI [MASKED] coronary vasospasm, dCHF, COPD, current smoker, Graves' s/p thyroidectomy, OSA not on CPAP, T2DM (A1C 6%), HL, hypokalemic periodic paralysis, admitted to OSH for biliary obstruction and found to have an ampullary mass now s/p stent placement who was transferred from [MASKED] for evaluation of persistent RUQ pain and inability to tolerate POs. Now tolerating regular diet with limited pain. ACUTE/ACTIVE PROBLEMS: # RUQ pain: # Ampullary adenoma: The patient initially presented to [MASKED] with acute RUQ pain and hyperbilirubinemia. He underwent an EUS/ERCP on [MASKED] at [MASKED] (after which he was transferred back to [MASKED]) showing an ampullary mass. Sphincterotomy was performed with biopsies (c/w adenoma) and biliary plastic stent placement. Cholestatic LFTs improved, but he was unable to tolerate a diet at [MASKED] secondary to post-prandial pain. CT A/P showed interval placement of internal biliary stent with associated pneumobilia but no biliary dilation or evidence of pancreatitis. He was treated with cipro/flagyl (initiated [MASKED] and was started on TPN via a RUE PICC at [MASKED] prior to being transferred back to [MASKED] for further evaluation. On arrival, CBC, LFTs, lipase were all WNL. Given his imaging and absence of fever/leukocytosis, cholangitis and cholecystitis were thought unlikely and antibiotics were discontinued (s/p 7d course). His pain was controlled with tylenol and very intermittent oxycodone. He was evaluated by the [MASKED] and [MASKED] surgery services. His ampullary mass was not thought to explain his pain in the absence of LFT abnormalities, and he was scheduled for outpatient surgical f/u with Dr. [MASKED] on [MASKED] at 8am to discuss possible, non-urgent surgical resection. Repeat ERCP was deferred. He was continued on TPN, weaned as his diet was advanced with resolution of his pain. At the time of discharge, he had been tolerating a regular diet for >24h with only minimal RUQ pain (1 out of 10, not associated with food) and no N/V. CEA and CA [MASKED] were sent, both WNL. He will f/u with Dr. [MASKED] as above and with his primary care doctor on [MASKED]. # Severe malnutrition: Severe malnutrition in the setting of acute illness, as evidenced by 6% weight loss in ~2 weeks & <50% energy intake compared to estimated energy needs for >5days. He was continued on TPN, initiated at [MASKED]. His diet was advanced, and he was tolerating a regular diet to meet his caloric needs at discharge. TPN was weaned and discontinued on [MASKED]. # Hyperglycemia: # T2DM: Hx of T2DM, on metformin and glipizide at home. Hperglycemic in house, likely in the setting of TPN. Home anti-hyperglycemics were held and an insulin sliding scale was initiated. In addition, insulin was added to TPN. Glipizide and metformin were reinitiated on discharge. CHRONIC/STABLE PROBLEMS: # COPD: Home Breo-Ellipta was replaced with Advair (given formulary issues), with albuterol PRN. Home regimen continued at discharge. # HFpEF: Appeared euvolemic. Home Lasix PRN was held in house and continued at discharge. Weight at discharge 111kg. # OSA: Has previously declined CPAP. No evidence of desaturations while hospitalized. Deferred further discussions to outpatient providers. # Hypothyroidism: TSH WNL. Continued home thyroid replacement. # pAF: Continued digoxin and metoprolol. Patient was not on anticoagulation. Deferred discussion about initiation of anticoagulation to PCP. # Nicotine dependence: Continued nicotine patches, prescribed on discharge. # Hypokalemic periodic paralysis: K was WNL without episodes. # HLD: Continued home statin. ** TRANSITIONAL ** [ ] f/u with Dr. [MASKED] on [MASKED] at 8 am to discuss ampullary mass resection [ ] will need repeat ERCP in 5 weeks to remove biliary stent [ ] f/u A1c (hyperglycemic in house, likely TPN) [ ] discuss anticoagulation for pAF [ ] discuss CPAP for OSA Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 175 mcg PO DAILY 2. GlipiZIDE XL 5 mg PO DAILY 3. albuterol sulfate 108 mcg inhalation QID:PRN 4. Aspirin EC 81 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Digoxin 0.25 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO QPM 8. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation BID 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Klor-Con M20 (potassium chloride) 30 mEq oral DAILY 11. Furosemide 20 mg PO DAILY PRN edema 12. Propranolol 10 mg PO TID:PRN palpitations Discharge Medications: 1. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour apply one patch daily Disp #*14 Patch Refills:*0 2. albuterol sulfate 108 mcg inhalation QID:PRN 3. Aspirin EC 81 mg PO DAILY 4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation BID 5. Digoxin 0.25 mg PO DAILY 6. Furosemide 20 mg PO DAILY PRN edema 7. GlipiZIDE XL 5 mg PO DAILY 8. Klor-Con M20 (potassium chloride) 30 mEq oral DAILY 9. Levothyroxine Sodium 175 mcg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Propranolol 10 mg PO TID:PRN palpitations 13. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Ampullary mass Biliary obstruction Post-prandial pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were transferred from [MASKED] for persistent abdominal pain after eating. You were continued on TPN, and your pain gradually improved with bowel rest. At the time of discharge, you were eating a regular diet without significant pain. Please follow up with Dr. [MASKED] on [MASKED] to discuss resection of the ampullary mass that was discovered. In addition, you will need a repeat ERCP in about 5 weeks to remove the plastic stent that was placed on [MASKED]. The ERCP group should call you with an appointment. Please follow up with your primary care doctor to discuss your other medical issues. We advise you to quit smoking and are providing you with a nicotine patch prescription on discharge. With best wishes, [MASKED] Medicine Followup Instructions: [MASKED]
[]
[ "I110", "I5032", "E1165", "I480", "F17210", "J449", "G4733", "I252", "E785" ]
[ "R1011: Right upper quadrant pain", "E43: Unspecified severe protein-calorie malnutrition", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D135: Benign neoplasm of extrahepatic bile ducts", "I480: Paroxysmal atrial fibrillation", "G723: Periodic paralysis", "E890: Postprocedural hypothyroidism", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J449: Chronic obstructive pulmonary disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9689: Presence of other specified functional implants", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified" ]
10,060,338
25,454,537
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Wound infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of CHF, MI ___ coronary vasospasm, COPD, Graves disease, HTN, HLD, hypokalemic periodic paralysis, NAFLD, current smoker of ___ pack a day, who previously developed obstructive jaundice secondary to a large obstructing tubulovillous adenoma of the ampulla of Vater who underwent a transduodenal ampullary resection and cholecystectomy with Dr. ___ on ___. He was discharged from the hospital on ___ and has been recovering well until he developed pain and erythema on the lateral aspect of his incision approximately 2 days ago. He also noted the area to be swollen and firm at that time. He then went to ___ yesterday where he underwent needle aspiration and subsequent I&D of the lateral aspect of the wound. A wick was then placed and the patient was discharged with a prescription for PO Bactrim. He was encouraged to present to ___ this morning. He rates his pain as ___ and notes that the redness and swelling has gone down since yesterday. He reports a subjective fever, chronic SOB and nausea. He states that he has not had a bowel movement since discharge but is still passing gas. He denies chest pain, vomiting, or diarrhea. Past Medical History: COPD pAFib MI ___ Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism ___ T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker ___ ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Transduodenal ampullectomy and cholecystectomy Social History: Smoking status - never [ ] former [ ] current [X] Pack-yrs: 40+ Alcohol use - Never [ ] Rarely [X] Daily [ ] H/O dependence [ ] Illicit drug use - denies Physical Exam: PE: V:98.0 F 66 HR 107/69 BP 18 RR 97% RA General - uncomfortable, no acute distress Cardiovascular - RRR, no appreciable murmur Respiratory - CTAB, some expiratory wheezing GI - abdomen soft, no rebound or guarding, bowel sounds active, right lateral edge of RUQ incision is erythematous, firm, and tender with moist-to-dry gauze packing in place, small sanguineous drainage. Skin - warm and dry Pertinent Results: ___ 04:45AM BLOOD WBC-7.7 RBC-4.65 Hgb-14.3 Hct-43.9 MCV-94 MCH-30.8 MCHC-32.6 RDW-14.0 RDWSD-47.8* Plt ___ ___ 04:45AM BLOOD Glucose-120* UreaN-9 Creat-0.9 Na-141 K-4.4 Cl-101 HCO3-28 AnGap-12 ___ 09:40AM BLOOD ALT-51* AST-39 AlkPhos-90 TotBili-0.3 ___ 04:45AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.4 MICROBIOLOGY; Pending Brief Hospital Course: The patient s/p transduodenal ampullary resection and cholecystectomy on ___ was admitted to General Surgery service with post operative wound infection. The patient's wound was slightly opened in ___ day prior his admission and packed with wick. In ED patient was afebrile with slightly elevated WBC. Patient was started on Vancomycin, his wound was open more medially and packed with moist-to-dry gauze. No pus was appreciated in the wound bed, small amount of sanguineous drainage was noticed. On HD 2, patient remained afebrile, WBC returned back to normal, incisional erythema and tenderness subsided. Patient was transitioned to Keflex, was able to tolerate regular diet and pain was well controlled. He was discharged home with ___ serviced for wound care, on oral antibiotics. He will f/u with surgery team on ___ for post op and wounf re-evaluation. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 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. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*126 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*11 5. Senna 8.6 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath 8. Aspirin 325 mg PO DAILY 9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN 10. coenzyme Q10 100 mg oral Q24H 11. Digoxin 0.25 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Levothyroxine Sodium 175 mcg PO DAILY 14. Magnesium Oxide 400 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Potassium Chloride 20 mEq PO DAILY 18. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 19. Rosuvastatin Calcium 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild do not exceed more then 3000 mg/day 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate take before dressing change 4. Polyethylene Glycol 17 g PO DAILY 5. Aspirin 325 mg PO DAILY 6. Digoxin 0.25 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Furosemide 20 mg PO DAILY 9. GlipiZIDE 5 mg PO BID 10. Levothyroxine Sodium 175 mcg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Rosuvastatin Calcium 40 mg PO QPM 15. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to the surgery service at ___ for evaluation and treatment of wound infection. You are now safe to return home to complete your recovery with the following instructions: . Please continue to change your wound dressing twice and day, also continue antibiotics as prescribed. Your wound will be re-evaluated in clinic on ___. Call ___ and ask to ___ ___ ream if develop fever, chill, more erythema around wound or increased drainage from the wound. . Please call your doctor or nurse practitioner if you experience 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 is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___
[ "T814XXA", "Y836", "Y929", "J449", "I480", "I252", "E890", "I110", "I5032", "E119", "E785", "K760", "G4733", "F17210", "E876" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Wound infection Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with history of CHF, MI [MASKED] coronary vasospasm, COPD, Graves disease, HTN, HLD, hypokalemic periodic paralysis, NAFLD, current smoker of [MASKED] pack a day, who previously developed obstructive jaundice secondary to a large obstructing tubulovillous adenoma of the ampulla of Vater who underwent a transduodenal ampullary resection and cholecystectomy with Dr. [MASKED] on [MASKED]. He was discharged from the hospital on [MASKED] and has been recovering well until he developed pain and erythema on the lateral aspect of his incision approximately 2 days ago. He also noted the area to be swollen and firm at that time. He then went to [MASKED] yesterday where he underwent needle aspiration and subsequent I&D of the lateral aspect of the wound. A wick was then placed and the patient was discharged with a prescription for PO Bactrim. He was encouraged to present to [MASKED] this morning. He rates his pain as [MASKED] and notes that the redness and swelling has gone down since yesterday. He reports a subjective fever, chronic SOB and nausea. He states that he has not had a bowel movement since discharge but is still passing gas. He denies chest pain, vomiting, or diarrhea. Past Medical History: COPD pAFib MI [MASKED] Coronary Vasospasm Graves' disease, thyroid storm, s/p thyroidectomy, now Hypothyroidism [MASKED] T2DM HL HTN Hypokalemic periodic paralysis Ampullary Adenoma NAFLD Cholelithiasis OSA not compliant with CPAP Current smoker [MASKED] ppd, 60 pack-yr hx) Surgical Hx: Thyroidectomy Hernia repair Vasectomy Tonsillectomy Transduodenal ampullectomy and cholecystectomy Social History: Smoking status - never [ ] former [ ] current [X] Pack-yrs: 40+ Alcohol use - Never [ ] Rarely [X] Daily [ ] H/O dependence [ ] Illicit drug use - denies Physical Exam: PE: V:98.0 F 66 HR 107/69 BP 18 RR 97% RA General - uncomfortable, no acute distress Cardiovascular - RRR, no appreciable murmur Respiratory - CTAB, some expiratory wheezing GI - abdomen soft, no rebound or guarding, bowel sounds active, right lateral edge of RUQ incision is erythematous, firm, and tender with moist-to-dry gauze packing in place, small sanguineous drainage. Skin - warm and dry Pertinent Results: [MASKED] 04:45AM BLOOD WBC-7.7 RBC-4.65 Hgb-14.3 Hct-43.9 MCV-94 MCH-30.8 MCHC-32.6 RDW-14.0 RDWSD-47.8* Plt [MASKED] [MASKED] 04:45AM BLOOD Glucose-120* UreaN-9 Creat-0.9 Na-141 K-4.4 Cl-101 HCO3-28 AnGap-12 [MASKED] 09:40AM BLOOD ALT-51* AST-39 AlkPhos-90 TotBili-0.3 [MASKED] 04:45AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.4 MICROBIOLOGY; Pending Brief Hospital Course: The patient s/p transduodenal ampullary resection and cholecystectomy on [MASKED] was admitted to General Surgery service with post operative wound infection. The patient's wound was slightly opened in [MASKED] day prior his admission and packed with wick. In ED patient was afebrile with slightly elevated WBC. Patient was started on Vancomycin, his wound was open more medially and packed with moist-to-dry gauze. No pus was appreciated in the wound bed, small amount of sanguineous drainage was noticed. On HD 2, patient remained afebrile, WBC returned back to normal, incisional erythema and tenderness subsided. Patient was transitioned to Keflex, was able to tolerate regular diet and pain was well controlled. He was discharged home with [MASKED] serviced for wound care, on oral antibiotics. He will f/u with surgery team on [MASKED] for post op and wounf re-evaluation. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 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. HYDROmorphone (Dilaudid) [MASKED] mg PO Q3H:PRN Pain - Severe RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*126 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*11 5. Senna 8.6 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath 8. Aspirin 325 mg PO DAILY 9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY:PRN 10. coenzyme Q10 100 mg oral Q24H 11. Digoxin 0.25 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Levothyroxine Sodium 175 mcg PO DAILY 14. Magnesium Oxide 400 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Potassium Chloride 20 mEq PO DAILY 18. Propranolol 10 mg PO Q8H:PRN Atrial fibrillation 19. Rosuvastatin Calcium 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild do not exceed more then 3000 mg/day 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate take before dressing change 4. Polyethylene Glycol 17 g PO DAILY 5. Aspirin 325 mg PO DAILY 6. Digoxin 0.25 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Furosemide 20 mg PO DAILY 9. GlipiZIDE 5 mg PO BID 10. Levothyroxine Sodium 175 mcg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Rosuvastatin Calcium 40 mg PO QPM 15. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the surgery service at [MASKED] for evaluation and treatment of wound infection. You are now safe to return home to complete your recovery with the following instructions: . Please continue to change your wound dressing twice and day, also continue antibiotics as prescribed. Your wound will be re-evaluated in clinic on [MASKED]. Call [MASKED] and ask to [MASKED] [MASKED] ream if develop fever, chill, more erythema around wound or increased drainage from the wound. . Please call your doctor or nurse practitioner if you experience 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 is not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]
[]
[ "Y929", "J449", "I480", "I252", "I110", "I5032", "E119", "E785", "G4733", "F17210" ]
[ "T814XXA: Infection following a procedure", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "J449: Chronic obstructive pulmonary disease, unspecified", "I480: Paroxysmal atrial fibrillation", "I252: Old myocardial infarction", "E890: Postprocedural hypothyroidism", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "K760: Fatty (change of) liver, not elsewhere classified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E876: Hypokalemia" ]
10,060,531
20,623,061
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: chest pain, SOB Major Surgical or Invasive Procedure: Cardiac Catheterization ___ History of Present Illness: Of note, the patient has another ___ MRN: ___. The patient is a ___ ___ with a past medical history significant for CAD s/p CABG x ___ and BMS to left main ramus in ___, CHF, AS, COPD ___ home O2), OSA (not on CPAP) who presented from rehab to ___ with new onset chest pressure, subsequently transferred to ___ ED. The history was gathered with a ___ interpreter over the phone, and from outside hospital notes and EMS notes. Around 1600 on ___, EMS was called to the patient's home. The ___ was present. The ___ stated that the patient was having left chest pressure. He was transported to ___. An EKG performed showed questionable ST elevations, so he was given heparin, nitroglycerin, Lasix 40 mg IV, and a full dose aspirin. The first troponin T at ___ was 0.04. His daughter requested transfer to ___ because that's where his CABG was performed. On arrival to ___, the patient states that his chest pain has not changed since his initial presentation. He denies abdominal pain, fevers, chills, cough. Cardiology was consulted. EKG was obtained. Per cardiology, this was likely chest pressure and ST changes from demand ischemia in the setting of volume overload. Recommended Lasix 120 mg IV, and start a Lasix drip at 10. The patient was maintained on a heparin drip and given 120mg IV Lasix in the ED. On arrival to the floor, the patient states that his breathing is better. He states that he started having left chest pain after he fell onto his side yesterday afternoon at home. He did not hit his head. The chest pain is worse with palpation. He reports that he has had multiple hospitalizations at ___ where he has been given "IV water pills." He reports that he has been eating and drinking less than normal. His weight today was 207 pounds, which she says is less than it normally is. He reports a ___ comes every other day to help with his medications. He reports compliance with his medications. Per outside hospital documentation, the patient was hospitalized at ___ ___ for chest pressure associated with lateral ST/T abnormalities, trop 0.03 x 3, chest pressure relieved following aggressive diuresis. Also with TTE ___ notable for EF 60%, mild MR, severe AS, mild-mod MR, RVSP 55-60, mild-mod WMA though not described other than mid septal, mod reduced RVSF, IVC dilated. There was no discharge weight recorded. He has had multiple hospitalizations there for CHF exacerbations and falls, and he refuses discharge to rehab, instead opting to go home with ___. Regarding the patient's cardiac history, he had a CABG x4 in ___ performed by Dr. ___: left internal mammary artery graft, left anterior descending reverse saphenous vein graft to the first marginal branch, diagonal branch, and left-sided PDA. He re-presented with chest pain to ___ in ___, and he had a bare metal stent to the left main ramus at that time. He has not been seen at ___ since then. EKG: Q waves in III, aVF, 1mm STD in V1, V2. Exam in the ED: Head/eyes: NCAT, PERRLA, EOMI. ENT/neck: OP WNL. Jugular venous distention to the earlobe sitting upright Chest/Resp: Mildly labored breathing on nonrebreather, saturation 100%. Decreased to a nasal cannula at home level of 8 L/min, saturating 95%. Poor aeration throughout all lung fields consistent with history of COPD. No wheezes or significant expiratory prolongation. Otherwise, clear to auscultation bilaterally. Cardiovascular: RRR, Normal S1/S2, no murmurs/rubs/gallops. Abdomen: Soft, nondistended. Nontender. Musc/Extr/Back: Lower extremities warm and well perfused; trace to 1+ symmetric edema. Skin: No rash. Warm and dry. Neuro: Speech fluent. Psych: Normal mood. Normal mentation. Labs notable for white blood cell count 11.3, hemoglobin 9.2, platelets 203, INR 1.3, BUN 80, creatinine 2.2, AST 52, ALT 15, lipase 181, BNP 5853, troponin 0.03, UA without evidence of infection. Patient's weight on arrival to ___ was 208 pounds Past Medical History: CAD status post CABG x4, ___, s/p BMS to left main-ramus in ___. CHF (last EF 60% ___ RV dysfunction Hypertension Aortic Stenosis COPD ___ L home O2) OSA (not on CPAP) GERD Seizure disorder CKD (baseline Cr 1.8) Pulmonary hypertension Prostate Cancer Pemphigus vulgaris s/p Appendectomy ___ Social History: ___ Family History: Mother had hypertension and CAD. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS:97.5PO 133 / 68L Sitting 63 24 90 6L GENERAL: NAD, nose bleed HEENT: nose bleed NECK: supple, unable to asses JVP given body habitus CV: RRR, 2 out of 6 crescendo decrescendo murmur best auscultated at the base PULM: Diminished breath sounds bilaterally, no crackles appreciated GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly CHEST WALL: Tenderness palpation in the lower left chest wall over the rib cage. No ecchymosis or erythema. EXTREMITIES: Chronic venous stasis changes bilaterally, no pitting edema. PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DISCHARGE PHYSICAL EXAM: ======================== VS: 97.7 PO 116 / 64 R Lying 87 24 94 5L oxymizer GENERAL: NAD, minimally verbal when awake, intermittently somnolent NECK: JVP ~12cm CV: Normal rate and rhythm. Grade ___ systolic murmur heard throughout precordium. PULM: CTAB anteriorly, no increased WOB with oxymizer on GI: soft, nondistended, nontender. EXTREMITIES: Chronic venous stasis changes bilaterally. No ___ edema, warm PULSES: 2+ radial pulses bilaterally NEURO: see above Pertinent Results: ADMISSION LABS: ============= ___ 09:51PM WBC-11.3* RBC-3.95* HGB-9.2* HCT-31.0* MCV-79* MCH-23.3* MCHC-29.7* RDW-19.6* RDWSD-54.8* ___ 09:51PM GLUCOSE-112* UREA N-80* CREAT-2.2* SODIUM-137 POTASSIUM-7.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-17 ___ 09:51PM ALT(SGPT)-15 AST(SGOT)-52* CK(CPK)-112 ALK PHOS-93 TOT BILI-0.3 ___ 09:51PM LIPASE-181* MICRO: ====== Negative Urine cultures ___ Negative Blood cultures ___ Negative c.diff ___ Negative MRSA screen ___ IMAGING: ======= CXR (___): Small right pleural effusion with associated basilar atelectasis. No definite evidence of pneumonia. Cardiac Catheterization (___): Elevated right heart filling pressure. Preserved cardiac index in the setting of anemia and hypoxia. Severe pulmonary hypertension and markedly eleavted PVR. Severe pulmonary hypertension. RUQ (___): Small volume ascites MR HEAD W/O CONTRAST (___): There is prominence of sulci and ventricles indicating mild to moderate brain atrophy. There is an incidental cavum septum pellucidum and vergae. Diffuse hyperintensities in the white matter extent from periventricular to the subcortical region indicating severe changes of small vessel disease. There are no acute infarcts seen on the diffusion images. There is no midline shift or hydrocephalus. The vascular flow voids are maintained. Mild mucosal thickening is seen in the ethmoid air cells. A deviated nasal septum to the left is also visualized. IMPRESSION: 1. No acute infarcts mass effect or hydrocephalus. 2. Severe changes of small vessel disease and brain atrophy. CT CHEST W/O CONTRAST (___): Thyroid is unremarkable. Mildly enlarged right lower paratracheal lymph node measures 1.3 cm (02:20). Pericardial lymph node measures 1.1 cm (02:32). Coarse calcifications are noted in the left hilum. Thoracic aorta is normal size. Mildly enlarged main pulmonary artery measures 3.8 cm in diameter. Coronary artery and aortic valve calcifications are heavy. There is no pericardial effusion. Trace right pleural effusion is noted. Mild bronchiectasis is noted in the lower lobes bilaterally. Small scattered subcentimeter areas of ground-glass opacities are identified (302:108, 58, 98, 38) Calcified granulomas are present in bilateral lower lobes. No suspicious bone or soft tissue lesion is identified. Compression deformity of T12 vertebral body is likely chronic. Please refer to separate report for CT abdomen and pelvis performed at the same time for details of abdominal findings. IMPRESSION: 1. Small scattered subcentimeter areas of ground-glass opacities are likely infectious/inflammatory. 2. Mildly enlarged mediastinal lymph nodes are likely reactive. CT ABD & PELVIS W/O CONTRAST (___): LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: Small volume abdominopelvic ascites HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: 2.3 cm hypodense lesion is identified in the uncinate process of the pancreas (02:35) 2.1 cm exophytic hypodense lesion is identified in the anterior aspect of the pancreatic body (02:20). 1.1 cm hypoechoic dense lesion is identified in the pancreatic tail (02:22). The pancreas has normal attenuation throughout. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Mildly enlarged spleen measures 15.2 cm. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Bilateral kidneys are atrophic. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: Foley catheter is in the bladder. Thickened appearance of the bladder wall may be due to collapsed state. There is mild surrounding fat stranding in setting of free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Heavy atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture.Multiple compression deformities of thoracolumbar spine appear chronic SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No bowel obstruction or other acute intestinal pathology is identified. 2. Mild thickening of the bladder with surrounding fat stranding is equivocal for cystitis. 3. 3 hypodense lesions in the pancreas measuring up to 2.3 cm are statistically likely IPMNs, however other neoplastic process cannot be excluded. Consider nonemergent MRCP for further characterization. 4. Small ascites and splenomegaly. RECOMMENDATION(S): Consider nonemergent MRCP. CAROTID SERIES ___: RIGHT: The right carotid vasculature has mild atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 51 cm/sec, with mild parvus et tardus waveforms. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 41, 53, and 42 cm/sec, respectively, with mild partial tardus waveforms. The peak end diastolic velocity in the right internal carotid artery is 13 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 74 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 59 cm/sec, with mild parvus et tardus waveforms. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 42, 50, and 61 cm/sec, respectively, with mild parvus et tardus waveforms. The peak end diastolic velocity in the left internal carotid artery is 13 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 79 cm/sec. The vertebral artery is not visualized. Periods of irregular cardiac rhythm. IMPRESSION: < 40% stenosis of the right internal carotid artery. < 40% stenosis of the left internal carotid artery. Antegrade flow of the right vertebral artery. Left vertebral artery is not visualized. Periods of irregular cardiac rhythm. Mild parvus et tardus waveforms in the bilateral common and internal carotid artery suggest central stenosis (e.g. Aortic stenosis) CT HEAD W/O CONTRAST (___): There is no evidence of infarctionhemorrhage,edema,mass or mass effect. There diffuse low-density in the subcortical and periventricular white matter that are nonspecific but likely sequela of chronic microvascular ischemic disease. There is calcified atherosclerosis at the bilateral carotid siphons and the V4 portions of the bilateral vertebral arteries. Incidentally noted is a cavum septi pellucidi et vergae. There is no evidence of fracture. There is mild mucosal thickening of the bilateral ethmoid air cells, maxillary and left sphenoid sinuses. The visualized portion of the other paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacement. IMPRESSION: 1. No evidence of mass, hemorrhage or infarction. 2. Unchanged extensive supratentorial white matter hypodensities which are nonspecific but likely sequela of chronic small vessel ischemic disease. 3. Unchanged mucosal thickening in the paranasal sinuses without evidence of air fluid level. 4. Incidentally noted cavum septi pellucidi et vergae. NOTABLE RESULTS: ================ ___ 09:51PM TSH-4.8* ___ 09:51PM FREE T4-0.7* DISCHARGE LABS: =============== ___ 04:39AM BLOOD Glucose-121* UreaN-64* Creat-1.7* Na-130* K-4.3 Cl-86* HCO3-28 AnGap-16 ___ 04:39AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.___ with a past medical history significant for CAD s/p CABG x ___ (LIMA-LAD, rSVG to OM1, OM2, and D2?) and BMS to left main ramus in ___, CHF (LVEF 60%, RV dysfunction), severe AS ___ 0.9-1.1 cm2), COPD ___ home O2), OSA (not on CPAP) who presented from rehab to ___ with fall and new onset chest pressure, found to have HF exacerbation, RV failure, severe pulmonary hypertension requiring inotropic-assisted diuresis. ACTIVE ISSUES: ============== # Acute on Chronic Heart Failure with preserved LVEF # RV failure # Tricuspid regurgitation # Severe type III pulmonary hypertension Patient initially admitted to the CCU for inotropy dependent diuresis and hypotension. RHC ___ demonstrated elevated RA pressure, elevated transpulmonary gradient, and normal PCWP concerning for RV failure and severe pulmonary hypertension. Per pulmonary HTN group, no therapies available. Likely secondary to long standing COPD, OSA. Dobutamine was able to be weaned off ___, although still requiring max doses of diuretics. Will be discharged on Bumex 6 mg PO TID boluses. Will also discharge on 40 mEq daily potassium repletion QD. Pt is intermittently unable to take PO medications iso delirium discussed below. Would consider transitioning to IV bumex 6 mg TID if he cannot take PO reliably to ensure euvolemia. Would further consider use of dobutamine to aid diuresis if bumex is not effective in maintaining euvolemia. Given end-stage heart failure and poor prognosis home heart failure medications such as lisinopril, isordil and spironolactone were discontinued as these medications unlikely to change clinical outcomes in the setting of end-stage RV failure. PICC and foley were kept in place at time of discharge, though would recommend discontinuation as soon as possible to minimize ongoing infectious risks. #Acute hypoxic respiratory failure #End Stage COPD #Cor Pulmonale Patient with known COPD on home ___. Admitted to CCU with acute hypoxic respiratory failure likely ___ pulmonary edema vs. COPD exacerbation vs. HAP. He completed doxycycline (___) empirically for COPD exacerbation along with inhalers, as well as vanc/ceftazidime x 7 day course for HAP (___). He was also aggressively diuresed as above. He was trialed on BiPAP, but did not tolerate this secondary to RV failure. Right heart catheterization as above, demonstrated severe Type III pulmonary hypertension. Pulmonary hypertension group was consulted and had no additional therapies to offer. No indication for home theophylline, and this was discontinued. Will continue on 5L-8L oximizer on discharge. #Goals of care Ongoing goals of care discussions with patient and family, including his daughter and healthcare proxy, ___. Family understands his current medical status including end-stage right heart failure and end-stage lung disease. Unfortunately, despite maximum medical interventions, his prognosis remains poor. The patient clearly voiced to us that he understands the end of his life is approaching. Patient had previously signed MOLST indicating his preference to be DNR/DNI. During admission per discussion with ___ the decision was made to defer further ICU transfers, though would address with ___ going forward to ensure this is consistent with her wishes. He and family would like to continue all non-invasive treatments for now and would not like to have hospice involved in care at this point. Palliative care was consulted, and are following. Will be discharged to ___ facility with palliative care follow up to continue these discussions. Of note, regular diet was continued with the understanding that patient is a known aspiration risk. #Moderate AS: ___ 0.9-1.1 cm2 as per recent TTE. Valvular disease likely causes him to be preload dependent, along with RV failure. Cardiac surgery was consulted. Felt that he was an extremely high risk surgical candidate, and TAVR unlikely to significantly improve symptoms given underlying RV failure and pulmonary hypertension. Further invasive procedures are not within goals of care. #Toxic/metabolic encephalopathy #AMS/confusional spells #Delirium During his admission he had frequent daily spells of confusion, inability to follow commands, and staring. He underwent MRI head showing extensive microvascular ischemic changes and moderate atrophy. Neuro exam remained normal. EEG with diffuse slowing, no seizure activity. Likely multi-factorial in the setting of low output state ___ RV failure, hypercarbia, uremia, and prolonged hospital course. #Aspiration PNA Patient with leukocytosis after hypoxic event on ___, vomiting while supine, CXR evidence concerning for atelectasis vs. aspiration. Patient started on vanc/cefepime/flagyl for empiric aspiration PNA coverage. Cefepime transitioned to ceftazidime given altered mental status on ___. Completed 5 day course (___). Speech and swallow was consulted. Per converstations with patient and family, they accept aspiration risk with regular diet. Tube feeds are not within goals of care. #Falls: Patient presented with fall while at home. Per report, he has had several recent falls. ___ evaluated the patient and recommended d/c to rehab. Continue fall precautions and physical therapy at rehab. CHRONIC ISSUES: ============== #HLD: #CAD: He is s/p CABG x ___ (LIMA-LAD, rSVG to OM1, OM2, and D2?) and BMS to left main ramus in ___. Ischemic EKG changes on presentation likely related to demand ischemia in setting of volume overload and hypotension. Continued home aspirin, discontinued home atorvastatin as likely not to provide benefit long term. #GERD: Continue ranitidine 150 mg BID. #Trigeminal neuralgia: Continue home oxcarbazepine 900 mg BID. #Constipation: Continue senna, Colace, Bisacodyl PRN. TRANSITIONAL ISSUES: ================== DISCHARGE CR: 1.7 DISCHARGE WEIGHT: 80.1 kg (___) DISCHARGE DIURETICS: Bumex 6 mg PO TID [ ] Discharged with foley has patient had previously expressed preference to leave it in. However, given the risk of UTI, would discuss discontinuation of foley with patient and his daughter, ___. [ ] ___ left in place at request of ___, would consider discontinuing to minimize infectious risks [ ] Follow up scheduled with cardiology, Dr. ___ ___. [ ] Will also have palliative care follow-up. Palliative care team is aware of his discharge and will call to make an appointment. [ ] Please continue goals of care conversations with patient and his daughter, ___. Currently DNR/DNI, no ICU transfer. MOLST completed. [ ] Discharged on PO bumex 6 mg TID. Will need daily weights. If weight gain > 5lbs can give 5 mg metolazone [ ] Consider transitioning back to IV bumex if pt cannot take PO to maintain euvolemia [ ] Consider adding dobutamine to maintain euvolemia if required, pending ___. Please discuss with ___. [ ] Monitor for hypokalemia given high doses of diuretics. Will send on 40 mEq QD, replete for K < 4.0. [ ] Recheck BMP on ___ or ___ to ensure stable potassium level and kidney function [ ] Discharging on Colace, senna, bisacodyl. Add lactulose if not having daily bowel movements. [ ] TSH just above nl and free T4 just under normal. Likely in the setting of acute illness. Consider recheck ___ after discharge pending goals of care. [ ] CT abdomen/pelvis with 3 hypodense lesions in the pancreas measuring up to 2.3 cm which are likely IPMNs. Will need surveillance as an outpatient pending goals of care. # CODE: DNR/DNI, confirmed # CONTACT/HCP: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Theophylline ER 200 mg PO DAILY 3. amLODIPine 2.5 mg PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Potassium Chloride 20 mEq PO DAILY 6. Torsemide 20 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Atorvastatin 20 mg PO QPM 11. Tiotropium Bromide 1 CAP IH DAILY 12. Vitamin D ___ UNIT PO 1X/WEEK (MO) 13. Metoprolol Succinate XL 100 mg PO DAILY 14. OXcarbazepine 900 mg PO BID 15. diclofenac sodium 1 % topical BID:PRN 16. Metolazone 5 mg PO 2X/WEEK (MO,TH) 17. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. Bumetanide 6 mg PO TID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 4. Lidocaine 5% Patch 1 PTCH TD QPM left rib cage pain 5. Senna 8.6 mg PO BID 6. Potassium Chloride 40 mEq PO DAILY 7. Ranitidine 150 mg PO BID:PRN heartburn 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. OXcarbazepine 900 mg PO BID 11. HELD- Metolazone 5 mg PO 2X/WEEK (MO,TH) This medication was held. Do not restart Metolazone until discussed with physician ___: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ================= Right heart failure Pulmonary hypertension Acute hypoxic respiratory failure Hospital acquired pneumonia COPD exacerbation Toxic metabolic encephalopathy Acute kidney injury SECONDARY DIAGNOSIS =================== Anemia Constipation Moderate aortic stenosis Chronic kidney disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you had chest pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital we determined that your heart function had deteriorated, specially the right side of your heart which pumps blood into your lungs - During your hospital stay we aggressively removed fluid to try and optimize your breathing as best we could. Despite removing as much fluid as safely possible you still required high levels of oxygen, which is likely due to the worsened heart failure mentioned above. - We optimized your heart medications as best we could WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. If your weight changes by more than 3 lbs please address this with your cardiologist and consider adjusting your diuretic medication. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "I130", "G92", "J690", "Z66", "I5033", "J9621", "J440", "J441", "K567", "E872", "L109", "I2510", "I350", "G4733", "I2720", "N189", "K219", "G40909", "I071", "I2781", "I959", "R296", "E785", "D631", "I4510", "D509", "R040", "G500", "K5900", "Z951", "Z8546", "Z7982", "Z8249", "W1830XA", "Z7902", "Z9981" ]
Allergies: [MASKED] Chief Complaint: chest pain, SOB Major Surgical or Invasive Procedure: Cardiac Catheterization [MASKED] History of Present Illness: Of note, the patient has another [MASKED] MRN: [MASKED]. The patient is a [MASKED] [MASKED] with a past medical history significant for CAD s/p CABG x [MASKED] and BMS to left main ramus in [MASKED], CHF, AS, COPD [MASKED] home O2), OSA (not on CPAP) who presented from rehab to [MASKED] with new onset chest pressure, subsequently transferred to [MASKED] ED. The history was gathered with a [MASKED] interpreter over the phone, and from outside hospital notes and EMS notes. Around 1600 on [MASKED], EMS was called to the patient's home. The [MASKED] was present. The [MASKED] stated that the patient was having left chest pressure. He was transported to [MASKED]. An EKG performed showed questionable ST elevations, so he was given heparin, nitroglycerin, Lasix 40 mg IV, and a full dose aspirin. The first troponin T at [MASKED] was 0.04. His daughter requested transfer to [MASKED] because that's where his CABG was performed. On arrival to [MASKED], the patient states that his chest pain has not changed since his initial presentation. He denies abdominal pain, fevers, chills, cough. Cardiology was consulted. EKG was obtained. Per cardiology, this was likely chest pressure and ST changes from demand ischemia in the setting of volume overload. Recommended Lasix 120 mg IV, and start a Lasix drip at 10. The patient was maintained on a heparin drip and given 120mg IV Lasix in the ED. On arrival to the floor, the patient states that his breathing is better. He states that he started having left chest pain after he fell onto his side yesterday afternoon at home. He did not hit his head. The chest pain is worse with palpation. He reports that he has had multiple hospitalizations at [MASKED] where he has been given "IV water pills." He reports that he has been eating and drinking less than normal. His weight today was 207 pounds, which she says is less than it normally is. He reports a [MASKED] comes every other day to help with his medications. He reports compliance with his medications. Per outside hospital documentation, the patient was hospitalized at [MASKED] [MASKED] for chest pressure associated with lateral ST/T abnormalities, trop 0.03 x 3, chest pressure relieved following aggressive diuresis. Also with TTE [MASKED] notable for EF 60%, mild MR, severe AS, mild-mod MR, RVSP 55-60, mild-mod WMA though not described other than mid septal, mod reduced RVSF, IVC dilated. There was no discharge weight recorded. He has had multiple hospitalizations there for CHF exacerbations and falls, and he refuses discharge to rehab, instead opting to go home with [MASKED]. Regarding the patient's cardiac history, he had a CABG x4 in [MASKED] performed by Dr. [MASKED]: left internal mammary artery graft, left anterior descending reverse saphenous vein graft to the first marginal branch, diagonal branch, and left-sided PDA. He re-presented with chest pain to [MASKED] in [MASKED], and he had a bare metal stent to the left main ramus at that time. He has not been seen at [MASKED] since then. EKG: Q waves in III, aVF, 1mm STD in V1, V2. Exam in the ED: Head/eyes: NCAT, PERRLA, EOMI. ENT/neck: OP WNL. Jugular venous distention to the earlobe sitting upright Chest/Resp: Mildly labored breathing on nonrebreather, saturation 100%. Decreased to a nasal cannula at home level of 8 L/min, saturating 95%. Poor aeration throughout all lung fields consistent with history of COPD. No wheezes or significant expiratory prolongation. Otherwise, clear to auscultation bilaterally. Cardiovascular: RRR, Normal S1/S2, no murmurs/rubs/gallops. Abdomen: Soft, nondistended. Nontender. Musc/Extr/Back: Lower extremities warm and well perfused; trace to 1+ symmetric edema. Skin: No rash. Warm and dry. Neuro: Speech fluent. Psych: Normal mood. Normal mentation. Labs notable for white blood cell count 11.3, hemoglobin 9.2, platelets 203, INR 1.3, BUN 80, creatinine 2.2, AST 52, ALT 15, lipase 181, BNP 5853, troponin 0.03, UA without evidence of infection. Patient's weight on arrival to [MASKED] was 208 pounds Past Medical History: CAD status post CABG x4, [MASKED], s/p BMS to left main-ramus in [MASKED]. CHF (last EF 60% [MASKED] RV dysfunction Hypertension Aortic Stenosis COPD [MASKED] L home O2) OSA (not on CPAP) GERD Seizure disorder CKD (baseline Cr 1.8) Pulmonary hypertension Prostate Cancer Pemphigus vulgaris s/p Appendectomy [MASKED] Social History: [MASKED] Family History: Mother had hypertension and CAD. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS:97.5PO 133 / 68L Sitting 63 24 90 6L GENERAL: NAD, nose bleed HEENT: nose bleed NECK: supple, unable to asses JVP given body habitus CV: RRR, 2 out of 6 crescendo decrescendo murmur best auscultated at the base PULM: Diminished breath sounds bilaterally, no crackles appreciated GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly CHEST WALL: Tenderness palpation in the lower left chest wall over the rib cage. No ecchymosis or erythema. EXTREMITIES: Chronic venous stasis changes bilaterally, no pitting edema. PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DISCHARGE PHYSICAL EXAM: ======================== VS: 97.7 PO 116 / 64 R Lying 87 24 94 5L oxymizer GENERAL: NAD, minimally verbal when awake, intermittently somnolent NECK: JVP ~12cm CV: Normal rate and rhythm. Grade [MASKED] systolic murmur heard throughout precordium. PULM: CTAB anteriorly, no increased WOB with oxymizer on GI: soft, nondistended, nontender. EXTREMITIES: Chronic venous stasis changes bilaterally. No [MASKED] edema, warm PULSES: 2+ radial pulses bilaterally NEURO: see above Pertinent Results: ADMISSION LABS: ============= [MASKED] 09:51PM WBC-11.3* RBC-3.95* HGB-9.2* HCT-31.0* MCV-79* MCH-23.3* MCHC-29.7* RDW-19.6* RDWSD-54.8* [MASKED] 09:51PM GLUCOSE-112* UREA N-80* CREAT-2.2* SODIUM-137 POTASSIUM-7.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-17 [MASKED] 09:51PM ALT(SGPT)-15 AST(SGOT)-52* CK(CPK)-112 ALK PHOS-93 TOT BILI-0.3 [MASKED] 09:51PM LIPASE-181* MICRO: ====== Negative Urine cultures [MASKED] Negative Blood cultures [MASKED] Negative c.diff [MASKED] Negative MRSA screen [MASKED] IMAGING: ======= CXR ([MASKED]): Small right pleural effusion with associated basilar atelectasis. No definite evidence of pneumonia. Cardiac Catheterization ([MASKED]): Elevated right heart filling pressure. Preserved cardiac index in the setting of anemia and hypoxia. Severe pulmonary hypertension and markedly eleavted PVR. Severe pulmonary hypertension. RUQ ([MASKED]): Small volume ascites MR HEAD W/O CONTRAST ([MASKED]): There is prominence of sulci and ventricles indicating mild to moderate brain atrophy. There is an incidental cavum septum pellucidum and vergae. Diffuse hyperintensities in the white matter extent from periventricular to the subcortical region indicating severe changes of small vessel disease. There are no acute infarcts seen on the diffusion images. There is no midline shift or hydrocephalus. The vascular flow voids are maintained. Mild mucosal thickening is seen in the ethmoid air cells. A deviated nasal septum to the left is also visualized. IMPRESSION: 1. No acute infarcts mass effect or hydrocephalus. 2. Severe changes of small vessel disease and brain atrophy. CT CHEST W/O CONTRAST ([MASKED]): Thyroid is unremarkable. Mildly enlarged right lower paratracheal lymph node measures 1.3 cm (02:20). Pericardial lymph node measures 1.1 cm (02:32). Coarse calcifications are noted in the left hilum. Thoracic aorta is normal size. Mildly enlarged main pulmonary artery measures 3.8 cm in diameter. Coronary artery and aortic valve calcifications are heavy. There is no pericardial effusion. Trace right pleural effusion is noted. Mild bronchiectasis is noted in the lower lobes bilaterally. Small scattered subcentimeter areas of ground-glass opacities are identified (302:108, 58, 98, 38) Calcified granulomas are present in bilateral lower lobes. No suspicious bone or soft tissue lesion is identified. Compression deformity of T12 vertebral body is likely chronic. Please refer to separate report for CT abdomen and pelvis performed at the same time for details of abdominal findings. IMPRESSION: 1. Small scattered subcentimeter areas of ground-glass opacities are likely infectious/inflammatory. 2. Mildly enlarged mediastinal lymph nodes are likely reactive. CT ABD & PELVIS W/O CONTRAST ([MASKED]): LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: Small volume abdominopelvic ascites HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: 2.3 cm hypodense lesion is identified in the uncinate process of the pancreas (02:35) 2.1 cm exophytic hypodense lesion is identified in the anterior aspect of the pancreatic body (02:20). 1.1 cm hypoechoic dense lesion is identified in the pancreatic tail (02:22). The pancreas has normal attenuation throughout. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Mildly enlarged spleen measures 15.2 cm. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Bilateral kidneys are atrophic. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: Foley catheter is in the bladder. Thickened appearance of the bladder wall may be due to collapsed state. There is mild surrounding fat stranding in setting of free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Heavy atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture.Multiple compression deformities of thoracolumbar spine appear chronic SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No bowel obstruction or other acute intestinal pathology is identified. 2. Mild thickening of the bladder with surrounding fat stranding is equivocal for cystitis. 3. 3 hypodense lesions in the pancreas measuring up to 2.3 cm are statistically likely IPMNs, however other neoplastic process cannot be excluded. Consider nonemergent MRCP for further characterization. 4. Small ascites and splenomegaly. RECOMMENDATION(S): Consider nonemergent MRCP. CAROTID SERIES [MASKED]: RIGHT: The right carotid vasculature has mild atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 51 cm/sec, with mild parvus et tardus waveforms. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 41, 53, and 42 cm/sec, respectively, with mild partial tardus waveforms. The peak end diastolic velocity in the right internal carotid artery is 13 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 74 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 59 cm/sec, with mild parvus et tardus waveforms. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 42, 50, and 61 cm/sec, respectively, with mild parvus et tardus waveforms. The peak end diastolic velocity in the left internal carotid artery is 13 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 79 cm/sec. The vertebral artery is not visualized. Periods of irregular cardiac rhythm. IMPRESSION: < 40% stenosis of the right internal carotid artery. < 40% stenosis of the left internal carotid artery. Antegrade flow of the right vertebral artery. Left vertebral artery is not visualized. Periods of irregular cardiac rhythm. Mild parvus et tardus waveforms in the bilateral common and internal carotid artery suggest central stenosis (e.g. Aortic stenosis) CT HEAD W/O CONTRAST ([MASKED]): There is no evidence of infarctionhemorrhage,edema,mass or mass effect. There diffuse low-density in the subcortical and periventricular white matter that are nonspecific but likely sequela of chronic microvascular ischemic disease. There is calcified atherosclerosis at the bilateral carotid siphons and the V4 portions of the bilateral vertebral arteries. Incidentally noted is a cavum septi pellucidi et vergae. There is no evidence of fracture. There is mild mucosal thickening of the bilateral ethmoid air cells, maxillary and left sphenoid sinuses. The visualized portion of the other paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacement. IMPRESSION: 1. No evidence of mass, hemorrhage or infarction. 2. Unchanged extensive supratentorial white matter hypodensities which are nonspecific but likely sequela of chronic small vessel ischemic disease. 3. Unchanged mucosal thickening in the paranasal sinuses without evidence of air fluid level. 4. Incidentally noted cavum septi pellucidi et vergae. NOTABLE RESULTS: ================ [MASKED] 09:51PM TSH-4.8* [MASKED] 09:51PM FREE T4-0.7* DISCHARGE LABS: =============== [MASKED] 04:39AM BLOOD Glucose-121* UreaN-64* Creat-1.7* Na-130* K-4.3 Cl-86* HCO3-28 AnGap-16 [MASKED] 04:39AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.[MASKED] with a past medical history significant for CAD s/p CABG x [MASKED] (LIMA-LAD, rSVG to OM1, OM2, and D2?) and BMS to left main ramus in [MASKED], CHF (LVEF 60%, RV dysfunction), severe AS [MASKED] 0.9-1.1 cm2), COPD [MASKED] home O2), OSA (not on CPAP) who presented from rehab to [MASKED] with fall and new onset chest pressure, found to have HF exacerbation, RV failure, severe pulmonary hypertension requiring inotropic-assisted diuresis. ACTIVE ISSUES: ============== # Acute on Chronic Heart Failure with preserved LVEF # RV failure # Tricuspid regurgitation # Severe type III pulmonary hypertension Patient initially admitted to the CCU for inotropy dependent diuresis and hypotension. RHC [MASKED] demonstrated elevated RA pressure, elevated transpulmonary gradient, and normal PCWP concerning for RV failure and severe pulmonary hypertension. Per pulmonary HTN group, no therapies available. Likely secondary to long standing COPD, OSA. Dobutamine was able to be weaned off [MASKED], although still requiring max doses of diuretics. Will be discharged on Bumex 6 mg PO TID boluses. Will also discharge on 40 mEq daily potassium repletion QD. Pt is intermittently unable to take PO medications iso delirium discussed below. Would consider transitioning to IV bumex 6 mg TID if he cannot take PO reliably to ensure euvolemia. Would further consider use of dobutamine to aid diuresis if bumex is not effective in maintaining euvolemia. Given end-stage heart failure and poor prognosis home heart failure medications such as lisinopril, isordil and spironolactone were discontinued as these medications unlikely to change clinical outcomes in the setting of end-stage RV failure. PICC and foley were kept in place at time of discharge, though would recommend discontinuation as soon as possible to minimize ongoing infectious risks. #Acute hypoxic respiratory failure #End Stage COPD #Cor Pulmonale Patient with known COPD on home [MASKED]. Admitted to CCU with acute hypoxic respiratory failure likely [MASKED] pulmonary edema vs. COPD exacerbation vs. HAP. He completed doxycycline ([MASKED]) empirically for COPD exacerbation along with inhalers, as well as vanc/ceftazidime x 7 day course for HAP ([MASKED]). He was also aggressively diuresed as above. He was trialed on BiPAP, but did not tolerate this secondary to RV failure. Right heart catheterization as above, demonstrated severe Type III pulmonary hypertension. Pulmonary hypertension group was consulted and had no additional therapies to offer. No indication for home theophylline, and this was discontinued. Will continue on 5L-8L oximizer on discharge. #Goals of care Ongoing goals of care discussions with patient and family, including his daughter and healthcare proxy, [MASKED]. Family understands his current medical status including end-stage right heart failure and end-stage lung disease. Unfortunately, despite maximum medical interventions, his prognosis remains poor. The patient clearly voiced to us that he understands the end of his life is approaching. Patient had previously signed MOLST indicating his preference to be DNR/DNI. During admission per discussion with [MASKED] the decision was made to defer further ICU transfers, though would address with [MASKED] going forward to ensure this is consistent with her wishes. He and family would like to continue all non-invasive treatments for now and would not like to have hospice involved in care at this point. Palliative care was consulted, and are following. Will be discharged to [MASKED] facility with palliative care follow up to continue these discussions. Of note, regular diet was continued with the understanding that patient is a known aspiration risk. #Moderate AS: [MASKED] 0.9-1.1 cm2 as per recent TTE. Valvular disease likely causes him to be preload dependent, along with RV failure. Cardiac surgery was consulted. Felt that he was an extremely high risk surgical candidate, and TAVR unlikely to significantly improve symptoms given underlying RV failure and pulmonary hypertension. Further invasive procedures are not within goals of care. #Toxic/metabolic encephalopathy #AMS/confusional spells #Delirium During his admission he had frequent daily spells of confusion, inability to follow commands, and staring. He underwent MRI head showing extensive microvascular ischemic changes and moderate atrophy. Neuro exam remained normal. EEG with diffuse slowing, no seizure activity. Likely multi-factorial in the setting of low output state [MASKED] RV failure, hypercarbia, uremia, and prolonged hospital course. #Aspiration PNA Patient with leukocytosis after hypoxic event on [MASKED], vomiting while supine, CXR evidence concerning for atelectasis vs. aspiration. Patient started on vanc/cefepime/flagyl for empiric aspiration PNA coverage. Cefepime transitioned to ceftazidime given altered mental status on [MASKED]. Completed 5 day course ([MASKED]). Speech and swallow was consulted. Per converstations with patient and family, they accept aspiration risk with regular diet. Tube feeds are not within goals of care. #Falls: Patient presented with fall while at home. Per report, he has had several recent falls. [MASKED] evaluated the patient and recommended d/c to rehab. Continue fall precautions and physical therapy at rehab. CHRONIC ISSUES: ============== #HLD: #CAD: He is s/p CABG x [MASKED] (LIMA-LAD, rSVG to OM1, OM2, and D2?) and BMS to left main ramus in [MASKED]. Ischemic EKG changes on presentation likely related to demand ischemia in setting of volume overload and hypotension. Continued home aspirin, discontinued home atorvastatin as likely not to provide benefit long term. #GERD: Continue ranitidine 150 mg BID. #Trigeminal neuralgia: Continue home oxcarbazepine 900 mg BID. #Constipation: Continue senna, Colace, Bisacodyl PRN. TRANSITIONAL ISSUES: ================== DISCHARGE CR: 1.7 DISCHARGE WEIGHT: 80.1 kg ([MASKED]) DISCHARGE DIURETICS: Bumex 6 mg PO TID [ ] Discharged with foley has patient had previously expressed preference to leave it in. However, given the risk of UTI, would discuss discontinuation of foley with patient and his daughter, [MASKED]. [ ] [MASKED] left in place at request of [MASKED], would consider discontinuing to minimize infectious risks [ ] Follow up scheduled with cardiology, Dr. [MASKED] [MASKED]. [ ] Will also have palliative care follow-up. Palliative care team is aware of his discharge and will call to make an appointment. [ ] Please continue goals of care conversations with patient and his daughter, [MASKED]. Currently DNR/DNI, no ICU transfer. MOLST completed. [ ] Discharged on PO bumex 6 mg TID. Will need daily weights. If weight gain > 5lbs can give 5 mg metolazone [ ] Consider transitioning back to IV bumex if pt cannot take PO to maintain euvolemia [ ] Consider adding dobutamine to maintain euvolemia if required, pending [MASKED]. Please discuss with [MASKED]. [ ] Monitor for hypokalemia given high doses of diuretics. Will send on 40 mEq QD, replete for K < 4.0. [ ] Recheck BMP on [MASKED] or [MASKED] to ensure stable potassium level and kidney function [ ] Discharging on Colace, senna, bisacodyl. Add lactulose if not having daily bowel movements. [ ] TSH just above nl and free T4 just under normal. Likely in the setting of acute illness. Consider recheck [MASKED] after discharge pending goals of care. [ ] CT abdomen/pelvis with 3 hypodense lesions in the pancreas measuring up to 2.3 cm which are likely IPMNs. Will need surveillance as an outpatient pending goals of care. # CODE: DNR/DNI, confirmed # CONTACT/HCP: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Theophylline ER 200 mg PO DAILY 3. amLODIPine 2.5 mg PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Potassium Chloride 20 mEq PO DAILY 6. Torsemide 20 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Atorvastatin 20 mg PO QPM 11. Tiotropium Bromide 1 CAP IH DAILY 12. Vitamin D [MASKED] UNIT PO 1X/WEEK (MO) 13. Metoprolol Succinate XL 100 mg PO DAILY 14. OXcarbazepine 900 mg PO BID 15. diclofenac sodium 1 % topical BID:PRN 16. Metolazone 5 mg PO 2X/WEEK (MO,TH) 17. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. Bumetanide 6 mg PO TID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 4. Lidocaine 5% Patch 1 PTCH TD QPM left rib cage pain 5. Senna 8.6 mg PO BID 6. Potassium Chloride 40 mEq PO DAILY 7. Ranitidine 150 mg PO BID:PRN heartburn 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. OXcarbazepine 900 mg PO BID 11. HELD- Metolazone 5 mg PO 2X/WEEK (MO,TH) This medication was held. Do not restart Metolazone until discussed with physician [MASKED]: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES ================= Right heart failure Pulmonary hypertension Acute hypoxic respiratory failure Hospital acquired pneumonia COPD exacerbation Toxic metabolic encephalopathy Acute kidney injury SECONDARY DIAGNOSIS =================== Anemia Constipation Moderate aortic stenosis Chronic kidney disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you had chest pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital we determined that your heart function had deteriorated, specially the right side of your heart which pumps blood into your lungs - During your hospital stay we aggressively removed fluid to try and optimize your breathing as best we could. Despite removing as much fluid as safely possible you still required high levels of oxygen, which is likely due to the worsened heart failure mentioned above. - We optimized your heart medications as best we could WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. If your weight changes by more than 3 lbs please address this with your cardiologist and consider adjusting your diuretic medication. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I130", "Z66", "E872", "I2510", "G4733", "N189", "K219", "E785", "D509", "K5900", "Z951", "Z7902" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "G92: Toxic encephalopathy", "J690: Pneumonitis due to inhalation of food and vomit", "Z66: Do not resuscitate", "I5033: Acute on chronic diastolic (congestive) heart failure", "J9621: Acute and chronic respiratory failure with hypoxia", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "K567: Ileus, unspecified", "E872: Acidosis", "L109: Pemphigus, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I350: Nonrheumatic aortic (valve) stenosis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2720: Pulmonary hypertension, unspecified", "N189: Chronic kidney disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I071: Rheumatic tricuspid insufficiency", "I2781: Cor pulmonale (chronic)", "I959: Hypotension, unspecified", "R296: Repeated falls", "E785: Hyperlipidemia, unspecified", "D631: Anemia in chronic kidney disease", "I4510: Unspecified right bundle-branch block", "D509: Iron deficiency anemia, unspecified", "R040: Epistaxis", "G500: Trigeminal neuralgia", "K5900: Constipation, unspecified", "Z951: Presence of aortocoronary bypass graft", "Z8546: Personal history of malignant neoplasm of prostate", "Z7982: Long term (current) use of aspirin", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "W1830XA: Fall on same level, unspecified, initial encounter", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z9981: Dependence on supplemental oxygen" ]
10,060,733
24,753,883
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Painless Jaundice Major Surgical or Invasive Procedure: ___ -- ERCP History of Present Illness: Mr. ___ is a ___ with h/o diabetes, HLD, HTN, bladder and prostate cancer s/p prostatectomy and cystectomy in ___ with urostomy, who developed painless jaundice over one week. He was found to have elevated LFTs and D-bili at ___ without obvious source of obstruction and was transferred to ___. Patient presented to his primary care physician for asymptomatic jaundice approx. 1 week ago. An abdominal CT was obtained and showed a gallbladder that was mildly distended without bile duct dilation in the liver and lymphadenopathy within the retroperitoneum concerning for recurrent bladder cancer below the diaphragm. A Chest CT was normal. Jaundice persisted and he had repeat labs drawn 3 days ago, notable for CO2 of 14, bilirubin of 9.8, direct bilirubin of 6.3, alk phos of 1100, AST 145, ALT 261. He represented to ___ yesterday with persistant lab abnormalities and a RUQUS showed extra and intra hepatic duct dilation without obvious source of obstruction. He was transferred to ___ for further eval. He denies abdominal pain, fever, diarrhea, nausea, vomiting, decrease in appetite, pruritus. Reports he has been losing weight and nausea. Denies any history of jaundice or liver disease previously. In the ED, initial VS were: 97.1 82 111/70 16 99% RA Labs showed: T bili 10.9, D bili 9.0, ALT 238 AP 1346, AST 187, Cr 1.9 Received: ___ 00:59 PO/NG Cephalexin 500 mg ___ 00:59 PO/NG Ciprofloxacin HCl 500 mg Transfer VS were: 98.0 88 113/60 16 99% RA On arrival to the floor, patient reports continuing to have completely asymptomatic jaundice. No pain or fevers. He does note he was diagnosed with a UTI several days and started on cephalexin and ciprofloxacin on the ___ and ___. No other acute complaints. Past Medical History: Bladder cancer s/p Cystectomy in ___ with urostomy - Follows with Dr. ___ in ___ on ___ T2DM, diet controlled HLD HTN Prostate cancer s/p Prostatectomy in ___ Social History: ___ Family History: Mother - lung ___ Father - DM, cardiac problems Physical Exam: ADMISSION EXAM ====================== VS: 97.4 116/77 81 18 98 Ra GENERAL: Adult male in NAD HEENT: AT/NC, MMM, jaundiced 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, urostomy in place without discharge or drainage DISCHARGE EXAM ======================= Vitals: 97.7, HR 85, 128/85, RR 18, 99% RA General: Alert, oriented, no acute distress, pleasant HEENT: Sclerae icteric, Oropharynx jaundiced Neck: suppl Lungs: CTAB CV: RRR Abdomen: soft, nontender, nondistended Ext: warm, no edema Neuro: answers questions appropriately Skin: mild jaundice Pertinent Results: LABS ON ADMISSION ========================== ___ 11:42PM BLOOD WBC-5.1 RBC-4.70 Hgb-12.5* Hct-37.0* MCV-79* MCH-26.6 MCHC-33.8 RDW-18.6* RDWSD-52.3* Plt ___ ___ 11:42PM BLOOD Neuts-64.6 Lymphs-15.4* Monos-8.9 Eos-8.9* Baso-1.2* Im ___ AbsNeut-3.27 AbsLymp-0.78* AbsMono-0.45 AbsEos-0.45 AbsBaso-0.06 ___ 11:42PM BLOOD Glucose-168* UreaN-27* Creat-1.9* Na-133 K-3.6 Cl-100 HCO3-16* AnGap-17* ___ 11:42PM BLOOD ALT-238* AST-187* AlkPhos-1346* TotBili-10.9* DirBili-9.0* IndBili-1.9 ___ 11:42PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.1 Mg-2.3 ___ 09:30AM BLOOD %HbA1c-6.4* eAG-137* ___ 09:30AM BLOOD calTIBC-289 Ferritn-360 TRF-222 OTHER LABS ========================== ___ 06:00AM BLOOD CEA-11.8* (NORMAL ___ DISCHARGE LABS ========================== ___ 06:00AM BLOOD WBC-5.6 RBC-4.15* Hgb-10.9* Hct-32.8* MCV-79* MCH-26.3 MCHC-33.2 RDW-19.1* RDWSD-54.2* Plt ___ ___ 06:00AM BLOOD Glucose-175* UreaN-31* Creat-2.0* Na-136 K-3.8 Cl-106 HCO3-16* AnGap-14 ___ 06:00AM BLOOD ALT-157* AST-81* AlkPhos-1012* TotBili-4.3* DirBili-2.8* IndBili-1.5 ___ 06:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1 REPORTS ========================== RUQUS at ___ Right upper quadrant ultrasound showed moderate intrahepatic and extrahepatic biliary ductal dilation with cause not identified. Further evaluation with CT or MRI/MRCP recommended. Distended gallbladder containing small amount of sludge. No definite sonographic evidence of acute cholecystitis MRCP ___. 3.0 x 2.6 cm ill-defined mass-like region of hypointense signal on T1 weighted imaging and hypoenhancement in the pancreatic head with restricted diffusion. Findings could reflect lymphoma, especially in the setting extensive retroperitoneal lymphadenopathy, or an inflammatory process such as autoimmune pancreatitis. Metastatic disease or primary pancreatic malignancy are also considerations but the latter is less likely given the absence of upstream pancreatic ductal dilatation. Correlate with biopsy/cytology. Depending on the results, short-term imaging follow-up may be helpful. 2. Extensive retroperitoneal adenopathy, differentials include metastatic disease versus lymphoma. 3. Common bile duct stent in place. Enhancement of the biliary duct and pneumobilia, likely reflect post procedural change. 4. 6 mm pancreatic cystic lesion, likely a side-branch IPMN. 5. Pancreas divisum. ERCP ___ A single stricture that was 15 mm long was seen at the lower third of the common bile duct. There was moderate post-obstructive dilation. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Cytology samples were obtained using a brush in the lower third of the common bile duct. A 8cm by ___ ___ biliary stent was placed successfully in the main duct. Brief Hospital Course: ___ year-old man with a history of bladder cancer with urostomy who presents with acute onset of painless jaundice. CT at OSH showed retroperitoneal lymphadenopathy. An ERCP was performed on ___ and a stent was placed. Brushings were taken from the bile duct. The bilirubin downtrended after stent was placed. An MRCP was performed, which showed a mass in the head of the pancreas. OTHER PROBLEMS ============================ # RP Lymph Nodes: Concern for malignancy. Ongoing discussion and workup as outpatient, consider LN Biopsy as outpatient # Microcytic anemia: Continue home iron # CKD: Renal function at baseline and did not improve with IV fluid # Metabolic acidosis: Likely due to CKD # T2DM: A1C 6.4%. Diet controlled. # Recent UTI: No growth on urine culture on admission. Antibiotics were stopped. TRANSITIONAL ISSUES ============================= - Pt to be discussed at ___ pancreatic conference during the evening of ___. He will be contacted with the f/u plan re: the pancreatic mass and painless jaundice - F/u cytology as outpatient, pending on discharge - F/u CA ___ as outpatient, pending on discharge - Consider RP Lymph Node Biopsy as outpatient - Repeat ERCP in 1 month for assessment of biliary tree and stent removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Cephalexin 500 mg PO Q12H 4. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Obstructive jaundice d/t pancreatic head mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with jaundice (yellow skin), in the setting of having known enlarged lymph nodes. You had an ERCP, a procedure that evaluates your bile ducts. It showed that you had a blockage, and a stent was placed to drain your bile. After the stent was placed, your bilirubin (the chemical that makes your skin yellow) dramatically decreased. You also had an MRI performed, which showed a mass in the head of the pancreas, likely the cause of the obstruction. During the ERCP, samples of the cells in the bile ducts were taken to see if they are cancerous, and what type of cancer they might be (cytology). You will get a phone call about this within 10 days. If you do not hear from anyone in 10 days, please call me at ___. Followup Instructions: ___
[ "K831", "C249", "N179", "E872", "I10", "D509", "N390", "E119", "E785", "Z8546", "Z8551", "J45909", "Z794", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Painless Jaundice Major Surgical or Invasive Procedure: [MASKED] -- ERCP History of Present Illness: Mr. [MASKED] is a [MASKED] with h/o diabetes, HLD, HTN, bladder and prostate cancer s/p prostatectomy and cystectomy in [MASKED] with urostomy, who developed painless jaundice over one week. He was found to have elevated LFTs and D-bili at [MASKED] without obvious source of obstruction and was transferred to [MASKED]. Patient presented to his primary care physician for asymptomatic jaundice approx. 1 week ago. An abdominal CT was obtained and showed a gallbladder that was mildly distended without bile duct dilation in the liver and lymphadenopathy within the retroperitoneum concerning for recurrent bladder cancer below the diaphragm. A Chest CT was normal. Jaundice persisted and he had repeat labs drawn 3 days ago, notable for CO2 of 14, bilirubin of 9.8, direct bilirubin of 6.3, alk phos of 1100, AST 145, ALT 261. He represented to [MASKED] yesterday with persistant lab abnormalities and a RUQUS showed extra and intra hepatic duct dilation without obvious source of obstruction. He was transferred to [MASKED] for further eval. He denies abdominal pain, fever, diarrhea, nausea, vomiting, decrease in appetite, pruritus. Reports he has been losing weight and nausea. Denies any history of jaundice or liver disease previously. In the ED, initial VS were: 97.1 82 111/70 16 99% RA Labs showed: T bili 10.9, D bili 9.0, ALT 238 AP 1346, AST 187, Cr 1.9 Received: [MASKED] 00:59 PO/NG Cephalexin 500 mg [MASKED] 00:59 PO/NG Ciprofloxacin HCl 500 mg Transfer VS were: 98.0 88 113/60 16 99% RA On arrival to the floor, patient reports continuing to have completely asymptomatic jaundice. No pain or fevers. He does note he was diagnosed with a UTI several days and started on cephalexin and ciprofloxacin on the [MASKED] and [MASKED]. No other acute complaints. Past Medical History: Bladder cancer s/p Cystectomy in [MASKED] with urostomy - Follows with Dr. [MASKED] in [MASKED] on [MASKED] T2DM, diet controlled HLD HTN Prostate cancer s/p Prostatectomy in [MASKED] Social History: [MASKED] Family History: Mother - lung [MASKED] Father - DM, cardiac problems Physical Exam: ADMISSION EXAM ====================== VS: 97.4 116/77 81 18 98 Ra GENERAL: Adult male in NAD HEENT: AT/NC, MMM, jaundiced 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, urostomy in place without discharge or drainage DISCHARGE EXAM ======================= Vitals: 97.7, HR 85, 128/85, RR 18, 99% RA General: Alert, oriented, no acute distress, pleasant HEENT: Sclerae icteric, Oropharynx jaundiced Neck: suppl Lungs: CTAB CV: RRR Abdomen: soft, nontender, nondistended Ext: warm, no edema Neuro: answers questions appropriately Skin: mild jaundice Pertinent Results: LABS ON ADMISSION ========================== [MASKED] 11:42PM BLOOD WBC-5.1 RBC-4.70 Hgb-12.5* Hct-37.0* MCV-79* MCH-26.6 MCHC-33.8 RDW-18.6* RDWSD-52.3* Plt [MASKED] [MASKED] 11:42PM BLOOD Neuts-64.6 Lymphs-15.4* Monos-8.9 Eos-8.9* Baso-1.2* Im [MASKED] AbsNeut-3.27 AbsLymp-0.78* AbsMono-0.45 AbsEos-0.45 AbsBaso-0.06 [MASKED] 11:42PM BLOOD Glucose-168* UreaN-27* Creat-1.9* Na-133 K-3.6 Cl-100 HCO3-16* AnGap-17* [MASKED] 11:42PM BLOOD ALT-238* AST-187* AlkPhos-1346* TotBili-10.9* DirBili-9.0* IndBili-1.9 [MASKED] 11:42PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.1 Mg-2.3 [MASKED] 09:30AM BLOOD %HbA1c-6.4* eAG-137* [MASKED] 09:30AM BLOOD calTIBC-289 Ferritn-360 TRF-222 OTHER LABS ========================== [MASKED] 06:00AM BLOOD CEA-11.8* (NORMAL [MASKED] DISCHARGE LABS ========================== [MASKED] 06:00AM BLOOD WBC-5.6 RBC-4.15* Hgb-10.9* Hct-32.8* MCV-79* MCH-26.3 MCHC-33.2 RDW-19.1* RDWSD-54.2* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-175* UreaN-31* Creat-2.0* Na-136 K-3.8 Cl-106 HCO3-16* AnGap-14 [MASKED] 06:00AM BLOOD ALT-157* AST-81* AlkPhos-1012* TotBili-4.3* DirBili-2.8* IndBili-1.5 [MASKED] 06:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1 REPORTS ========================== RUQUS at [MASKED] Right upper quadrant ultrasound showed moderate intrahepatic and extrahepatic biliary ductal dilation with cause not identified. Further evaluation with CT or MRI/MRCP recommended. Distended gallbladder containing small amount of sludge. No definite sonographic evidence of acute cholecystitis MRCP [MASKED]. 3.0 x 2.6 cm ill-defined mass-like region of hypointense signal on T1 weighted imaging and hypoenhancement in the pancreatic head with restricted diffusion. Findings could reflect lymphoma, especially in the setting extensive retroperitoneal lymphadenopathy, or an inflammatory process such as autoimmune pancreatitis. Metastatic disease or primary pancreatic malignancy are also considerations but the latter is less likely given the absence of upstream pancreatic ductal dilatation. Correlate with biopsy/cytology. Depending on the results, short-term imaging follow-up may be helpful. 2. Extensive retroperitoneal adenopathy, differentials include metastatic disease versus lymphoma. 3. Common bile duct stent in place. Enhancement of the biliary duct and pneumobilia, likely reflect post procedural change. 4. 6 mm pancreatic cystic lesion, likely a side-branch IPMN. 5. Pancreas divisum. ERCP [MASKED] A single stricture that was 15 mm long was seen at the lower third of the common bile duct. There was moderate post-obstructive dilation. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Cytology samples were obtained using a brush in the lower third of the common bile duct. A 8cm by [MASKED] [MASKED] biliary stent was placed successfully in the main duct. Brief Hospital Course: [MASKED] year-old man with a history of bladder cancer with urostomy who presents with acute onset of painless jaundice. CT at OSH showed retroperitoneal lymphadenopathy. An ERCP was performed on [MASKED] and a stent was placed. Brushings were taken from the bile duct. The bilirubin downtrended after stent was placed. An MRCP was performed, which showed a mass in the head of the pancreas. OTHER PROBLEMS ============================ # RP Lymph Nodes: Concern for malignancy. Ongoing discussion and workup as outpatient, consider LN Biopsy as outpatient # Microcytic anemia: Continue home iron # CKD: Renal function at baseline and did not improve with IV fluid # Metabolic acidosis: Likely due to CKD # T2DM: A1C 6.4%. Diet controlled. # Recent UTI: No growth on urine culture on admission. Antibiotics were stopped. TRANSITIONAL ISSUES ============================= - Pt to be discussed at [MASKED] pancreatic conference during the evening of [MASKED]. He will be contacted with the f/u plan re: the pancreatic mass and painless jaundice - F/u cytology as outpatient, pending on discharge - F/u CA [MASKED] as outpatient, pending on discharge - Consider RP Lymph Node Biopsy as outpatient - Repeat ERCP in 1 month for assessment of biliary tree and stent removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Cephalexin 500 mg PO Q12H 4. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Obstructive jaundice d/t pancreatic head mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with jaundice (yellow skin), in the setting of having known enlarged lymph nodes. You had an ERCP, a procedure that evaluates your bile ducts. It showed that you had a blockage, and a stent was placed to drain your bile. After the stent was placed, your bilirubin (the chemical that makes your skin yellow) dramatically decreased. You also had an MRI performed, which showed a mass in the head of the pancreas, likely the cause of the obstruction. During the ERCP, samples of the cells in the bile ducts were taken to see if they are cancerous, and what type of cancer they might be (cytology). You will get a phone call about this within 10 days. If you do not hear from anyone in 10 days, please call me at [MASKED]. Followup Instructions: [MASKED]
[]
[ "N179", "E872", "I10", "D509", "N390", "E119", "E785", "J45909", "Z794", "Z87891" ]
[ "K831: Obstruction of bile duct", "C249: Malignant neoplasm of biliary tract, unspecified", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "I10: Essential (primary) hypertension", "D509: Iron deficiency anemia, unspecified", "N390: Urinary tract infection, site not specified", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z8551: Personal history of malignant neoplasm of bladder", "J45909: Unspecified asthma, uncomplicated", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]
10,060,749
23,640,770
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Percodan Attending: ___. Chief Complaint: Acute Blood Loss Anemia due to Hematemasis Major Surgical or Invasive Procedure: EGD to evaluate esophageal stent placement History of Present Illness: ___ year old Female who underwent an esophageal stent and dilation for an esophageal stricture here at ___ the day prior to admission, who had 2 espisodes of large volume coffee grounds emesis the day of presentation. Of note she stopped her DOAC 2 days prior to the procedure as per the GI team plan. The patient presented to the ___ ED and was briefly sent to the FICU prior to undergoing an EGD from the advanced endoscopy team which was unrevealing with an appropriately placed stent which was left in place, no source of bleeding was noted. Patient has a history of esophageal stents for the prior ___ years, after initially developing a stricture after an episode of gastroenteritis with esophageal tear. Initial vitals in the ___ ED: 98.6 , 102 , 154/69, 18, 100% She was initially sent to the ___ for policy given her clinical stability at the time, but on weekends that is apparently the policy prior to ERCP/EGD. Past Medical History: Atrial Fibrillation on Apixaban Cardiac Stent ___ hypertension arthritis seasonal allergies with sinus infections left total hip replacement TAH/BSO in ___ Social History: ___ Family History: Mother: CAD, ICH Father: ___ CA Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, + Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia, + Hematemesis PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: HR 90, afebrile, SBP 121/71 GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Motor ___ ___ Flex/Ext Pertinent Results: ___ 09:30AM BLOOD WBC-13.4* RBC-3.36* Hgb-9.4* Hct-30.6* MCV-91 MCH-28.0 MCHC-30.7* RDW-14.1 RDWSD-47.1* Plt ___ ___ 02:50AM BLOOD WBC-8.3 RBC-3.46* Hgb-9.7* Hct-31.4* MCV-91 MCH-28.0 MCHC-30.9* RDW-14.0 RDWSD-46.4* Plt ___ ___ 09:30AM BLOOD Neuts-75.9* Lymphs-17.4* Monos-6.0 Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.16* AbsLymp-2.34 AbsMono-0.81* AbsEos-0.00* AbsBaso-0.04 ___ 02:50AM BLOOD Neuts-86.6* Lymphs-11.3* Monos-1.4* Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.18* AbsLymp-0.94* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.02 ___ 02:50AM BLOOD ___ PTT-31.2 ___ ___ 02:50AM BLOOD Glucose-154* UreaN-25* Creat-1.0 Na-141 K-5.4 Cl-100 HCO3-23 AnGap-18 ___ 02:50AM BLOOD estGFR-Using this patient's age, gender, and serum creatinine value of 1.0, estimated GFR (eGFR) is likely between 54 and 65 mL/min/1.73 m2, provided the serum creatinine value is stable. (Patients with more muscle mass and better nutritional status are more likely to be at the higher end of this range.) An eGFR < 60 suggests kidney disease in those below the age of ___ and there may be kidney disease in those over ___.\ ___ 03:23AM BLOOD Lactate-1.7 EGD ___: Normal Stomach, Normal Duodenum, In the distal third of the esophagus, a partially covered stent is seen as expected in excellent position. It extended 2-3cm beyond the GE junction as noted on retroflexion. The proximal uncovered part of the stent had tissue ingrowth and appeared friable. No active oozing/bleeding or stigmata of recent bleeding were seen. Discussed with Dr. ___ the procedure and we agreed to leave the stent in place given excellent position. The stent was widely patent at the proximal and distal aspects and allowed free passage of an adult EGD scope. Discharge Labs ___ 06:50AM BLOOD WBC-9.1 RBC-3.06* Hgb-8.4* Hct-27.6* MCV-90 MCH-27.5 MCHC-30.4* RDW-13.7 RDWSD-45.2 Plt ___ ___ 08:02AM BLOOD Neuts-77.2* Lymphs-14.6* Monos-7.1 Eos-0.2* Baso-0.4 Im ___ AbsNeut-8.04* AbsLymp-1.52 AbsMono-0.74 AbsEos-0.02* AbsBaso-0.___. Acute Blood Loss Anemia due to Gastric Bleeding - No source identified on EGD. Most likely due to the stent procedure. - ERCP consultation - Advanced diet to regular on the day of discharge, though she did have some episodes of nausea which were treated with Zofran. - High dose PPI (Omeprazole 40 TID) IV then switched to PO when able to eat - Serial hematocrits were stable and she did not require a blood transfusion, thus eliquis was restarted. 2. Primary Hypertension - Metoprolol continued, although with caution given bleeding risk 3. Atrial Fibrillation with RVR Developed RVR with rates to the 180s. Pt complained of palpitations but BP was stable. No SOB, CP or ST depressions on EKG. troponin remained normal <0.06. - Metoprolol uptitrated from 12.5 BID to QID but decreased to TID due to pt complaints of dizziness (which were more likely due to poor po). Pt was bolused with 500 cc of fluid for this. - Holding Apixaban 4. CAD - Metoprolol 5. Orthostasis - Pt complained of dizziness while getting up out of bed but SBP was 120 and HR 90. - received 500 cc IVF as this was presumed to be due to poor po - -Metoprolol uptitrated from 12.5 BID to QID but decreased to TID OUTSTANDING ISSUES [ ] Metoprolol uptitrated from 12.5 BID to QID but decreased to TID due to pt complaints of dizziness (which were more likely due to poor po). [ ] Pt received high dose PPI (Omeprazole 40 TID) IV then switched to PO when able to eat Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Tartrate 25 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Famotidine 20 mg PO QHS 5. Rosuvastatin Calcium 5 mg PO QPM 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Tartrate 25 mg PO DAILY --> UPTITRATED to 37.5 mg on discharge 3. Apixaban 5 mg PO BID 4. Famotidine 20 mg PO QHS 5. Rosuvastatin Calcium 5 mg PO QPM 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. NEW: po pantoprazole twice daily 9. NEW: Zofran 4 mg q4h prn Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hematemesis after esophageal stent placement Atrial fibrillation with RVR Discharge Condition: stable Discharge Instructions: You were admitted to the hospital due to coughing up blood, also known as hematemesis. This was most likely due to an esophageal stent placement. The gastroenterologists performed an endoscopy to evaluate the placement of the stent and felt it was situated well in your esophagus. Since your hematemesis resolved we restarted your blood thinner. We also increased your dose of metoprolol from 12.5 mg twice daily to 12.5 mg every 8 hours. Please follow up with your cardiologist regarding this dosage change. Followup Instructions: ___
[ "K91840", "K920", "D62", "I10", "I2510", "I4891", "I951", "D508", "E559", "K219", "J9801", "G4700", "E785", "R1310", "Z7901", "Z955" ]
Allergies: Percocet / Percodan Chief Complaint: Acute Blood Loss Anemia due to Hematemasis Major Surgical or Invasive Procedure: EGD to evaluate esophageal stent placement History of Present Illness: [MASKED] year old Female who underwent an esophageal stent and dilation for an esophageal stricture here at [MASKED] the day prior to admission, who had 2 espisodes of large volume coffee grounds emesis the day of presentation. Of note she stopped her DOAC 2 days prior to the procedure as per the GI team plan. The patient presented to the [MASKED] ED and was briefly sent to the FICU prior to undergoing an EGD from the advanced endoscopy team which was unrevealing with an appropriately placed stent which was left in place, no source of bleeding was noted. Patient has a history of esophageal stents for the prior [MASKED] years, after initially developing a stricture after an episode of gastroenteritis with esophageal tear. Initial vitals in the [MASKED] ED: 98.6 , 102 , 154/69, 18, 100% She was initially sent to the [MASKED] for policy given her clinical stability at the time, but on weekends that is apparently the policy prior to ERCP/EGD. Past Medical History: Atrial Fibrillation on Apixaban Cardiac Stent [MASKED] hypertension arthritis seasonal allergies with sinus infections left total hip replacement TAH/BSO in [MASKED] Social History: [MASKED] Family History: Mother: CAD, ICH Father: [MASKED] CA Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, + Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia, + Hematemesis PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: HR 90, afebrile, SBP 121/71 GEN: NAD Pain: [MASKED] HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Motor [MASKED] [MASKED] Flex/Ext Pertinent Results: [MASKED] 09:30AM BLOOD WBC-13.4* RBC-3.36* Hgb-9.4* Hct-30.6* MCV-91 MCH-28.0 MCHC-30.7* RDW-14.1 RDWSD-47.1* Plt [MASKED] [MASKED] 02:50AM BLOOD WBC-8.3 RBC-3.46* Hgb-9.7* Hct-31.4* MCV-91 MCH-28.0 MCHC-30.9* RDW-14.0 RDWSD-46.4* Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-75.9* Lymphs-17.4* Monos-6.0 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-10.16* AbsLymp-2.34 AbsMono-0.81* AbsEos-0.00* AbsBaso-0.04 [MASKED] 02:50AM BLOOD Neuts-86.6* Lymphs-11.3* Monos-1.4* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-7.18* AbsLymp-0.94* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.02 [MASKED] 02:50AM BLOOD [MASKED] PTT-31.2 [MASKED] [MASKED] 02:50AM BLOOD Glucose-154* UreaN-25* Creat-1.0 Na-141 K-5.4 Cl-100 HCO3-23 AnGap-18 [MASKED] 02:50AM BLOOD estGFR-Using this patient's age, gender, and serum creatinine value of 1.0, estimated GFR (eGFR) is likely between 54 and 65 mL/min/1.73 m2, provided the serum creatinine value is stable. (Patients with more muscle mass and better nutritional status are more likely to be at the higher end of this range.) An eGFR < 60 suggests kidney disease in those below the age of [MASKED] and there may be kidney disease in those over [MASKED].\ [MASKED] 03:23AM BLOOD Lactate-1.7 EGD [MASKED]: Normal Stomach, Normal Duodenum, In the distal third of the esophagus, a partially covered stent is seen as expected in excellent position. It extended 2-3cm beyond the GE junction as noted on retroflexion. The proximal uncovered part of the stent had tissue ingrowth and appeared friable. No active oozing/bleeding or stigmata of recent bleeding were seen. Discussed with Dr. [MASKED] the procedure and we agreed to leave the stent in place given excellent position. The stent was widely patent at the proximal and distal aspects and allowed free passage of an adult EGD scope. Discharge Labs [MASKED] 06:50AM BLOOD WBC-9.1 RBC-3.06* Hgb-8.4* Hct-27.6* MCV-90 MCH-27.5 MCHC-30.4* RDW-13.7 RDWSD-45.2 Plt [MASKED] [MASKED] 08:02AM BLOOD Neuts-77.2* Lymphs-14.6* Monos-7.1 Eos-0.2* Baso-0.4 Im [MASKED] AbsNeut-8.04* AbsLymp-1.52 AbsMono-0.74 AbsEos-0.02* AbsBaso-0.[MASKED]. Acute Blood Loss Anemia due to Gastric Bleeding - No source identified on EGD. Most likely due to the stent procedure. - ERCP consultation - Advanced diet to regular on the day of discharge, though she did have some episodes of nausea which were treated with Zofran. - High dose PPI (Omeprazole 40 TID) IV then switched to PO when able to eat - Serial hematocrits were stable and she did not require a blood transfusion, thus eliquis was restarted. 2. Primary Hypertension - Metoprolol continued, although with caution given bleeding risk 3. Atrial Fibrillation with RVR Developed RVR with rates to the 180s. Pt complained of palpitations but BP was stable. No SOB, CP or ST depressions on EKG. troponin remained normal <0.06. - Metoprolol uptitrated from 12.5 BID to QID but decreased to TID due to pt complaints of dizziness (which were more likely due to poor po). Pt was bolused with 500 cc of fluid for this. - Holding Apixaban 4. CAD - Metoprolol 5. Orthostasis - Pt complained of dizziness while getting up out of bed but SBP was 120 and HR 90. - received 500 cc IVF as this was presumed to be due to poor po - -Metoprolol uptitrated from 12.5 BID to QID but decreased to TID OUTSTANDING ISSUES [ ] Metoprolol uptitrated from 12.5 BID to QID but decreased to TID due to pt complaints of dizziness (which were more likely due to poor po). [ ] Pt received high dose PPI (Omeprazole 40 TID) IV then switched to PO when able to eat Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Tartrate 25 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Famotidine 20 mg PO QHS 5. Rosuvastatin Calcium 5 mg PO QPM 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Tartrate 25 mg PO DAILY --> UPTITRATED to 37.5 mg on discharge 3. Apixaban 5 mg PO BID 4. Famotidine 20 mg PO QHS 5. Rosuvastatin Calcium 5 mg PO QPM 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. NEW: po pantoprazole twice daily 9. NEW: Zofran 4 mg q4h prn Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Hematemesis after esophageal stent placement Atrial fibrillation with RVR Discharge Condition: stable Discharge Instructions: You were admitted to the hospital due to coughing up blood, also known as hematemesis. This was most likely due to an esophageal stent placement. The gastroenterologists performed an endoscopy to evaluate the placement of the stent and felt it was situated well in your esophagus. Since your hematemesis resolved we restarted your blood thinner. We also increased your dose of metoprolol from 12.5 mg twice daily to 12.5 mg every 8 hours. Please follow up with your cardiologist regarding this dosage change. Followup Instructions: [MASKED]
[]
[ "D62", "I10", "I2510", "I4891", "K219", "G4700", "E785", "Z7901", "Z955" ]
[ "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "K920: Hematemesis", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I4891: Unspecified atrial fibrillation", "I951: Orthostatic hypotension", "D508: Other iron deficiency anemias", "E559: Vitamin D deficiency, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J9801: Acute bronchospasm", "G4700: Insomnia, unspecified", "E785: Hyperlipidemia, unspecified", "R1310: Dysphagia, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z955: Presence of coronary angioplasty implant and graft" ]
10,060,863
28,867,198
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Vioxx / Motrin / phenobarbital / latex / gluten Attending: ___. Chief Complaint: dizziness, dyspnea, palpitations Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with a history of paroxysmal Atrial fib presents with palpitations. She presented today with 12 hours of continuous palpitations and irregular heartbeat. She states she woke this morning and noticed that her heartbeat felt irregular. The feeling persisted throughout the day. She knew she was in Atrial Fibrillation. She has been having on and off palpitations for one month, usually only lasting one hour, but this did not resolve. She also reports a few days of dizziness, as well as DOE when walking up hills since ___. She has a history of wheezing due to asthma which is chronic. She denies any chest pain, orthopnea, leg swelling, weight gain, fever, chills, urinary symptoms, nausea, vomiting, diarrhea. She has noted some mild bilateral breast tenderness in the last ___ days. Appetite has been poor. She is followed by Dr. ___ cardiology and is not on anticoagulation. She previously avoided anticoagulation due to h/o absence seizures and fall concern. She says her seizures have been very well controlled for years, no fall for over ___ years. She still has seizures daily but they are short lived. She is willing to be anticoagulated if clinically recommended. Past Medical History: Atrial fib/flutter, paroxysmal Cervical radiculopathy Asthma Celiac Sprue Osteopenia H/o seizures Vitamin D deficiency Allergic Rhinitis Spinal stenosis Hyperlipidemia Social History: ___ Family History: - Grandfather with h/o MI in his ___ - Father: heart murmur, cerebral aneurysm - Mother: irregular heart rate, hypertension, CVA age ___, cerebral aneurysm Physical Exam: ADMISSION EXAM ========================== VS: 97.8, BP 108 / 73, HR 72, RR 17, 98 RA GENERAL: NAD, well appearing HEENT: AT/NC, anicteric sclera NECK: supple, no LAD HEART: Irregular, regular rate, no murmurs LUNGS: Bilateral end-expiratory wheezing equal on both sides, no rales, no resp distress GI: abdomen soft, nontender EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&O grossly, face symmetric, moving all extremities LYMPH: No axillary adenopathy SKIN: Skin tag in Right axilla DISCHARGE EXAM ========================== 24 HR Data (last updated ___ @ 1411) Temp: 97.7 (Tm 98.3), BP: 96/64 (90-101/54 (manual)-67), HR: 77 (71-142), RR: 17 (___), O2 sat: 96% (95-98), O2 delivery: Ra, Wt: 123.2 lb/55.88 kg GENERAL: Well appearing woman in no acute distress. Comfortable. NEURO: AAOx3. CNII-XII grossly intact. Strength ___ in upper and lower extremities bilaterally. Sensation grossly intact. HEENT: NCAT. EOMI. MMM. CARDIAC: Irregular rhythm, normal rate. Normal S1/S2. No murmurs, rubs, or gallops. PULMONARY: Diffuse expiratory wheezing. Breathing comfortably on room air. ABDOMEN: Soft, non-tender, non-distended. BACK: ___ erythematous papules along right back wrapping around to right mid-breast. EXTREMITIES: Warm, well perfused, non-edematous. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS ========================== ___ 07:39PM BLOOD WBC-4.7 RBC-4.52 Hgb-14.5 Hct-43.6 MCV-97 MCH-32.1* MCHC-33.3 RDW-12.2 RDWSD-43.2 Plt ___ ___ 07:39PM BLOOD Neuts-63.1 ___ Monos-7.4 Eos-2.3 Baso-0.4 Im ___ AbsNeut-2.98 AbsLymp-1.26 AbsMono-0.35 AbsEos-0.11 AbsBaso-0.02 ___ 07:39PM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-142 K-4.2 Cl-101 HCO3-27 AnGap-14 ___ 07:39PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1 PERTINENT LABS ========================== ___ 07:35AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-143 K-4.4 Cl-104 HCO3-29 AnGap-10 ___ 07:39PM BLOOD cTropnT-<0.01 ___ 02:00AM BLOOD cTropnT-<0.01 DISCHARGE LABS ========================== ___ 07:35AM BLOOD WBC-4.0 RBC-4.53 Hgb-14.4 Hct-43.7 MCV-97 MCH-31.8 MCHC-33.0 RDW-11.9 RDWSD-42.1 Plt ___ ___ 07:35AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-143 K-4.4 Cl-104 HCO3-29 AnGap-10 ___ 07:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 PERTINENT STUDIES ========================== TTE (___) Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. STRESS EKG (___/) Non-specific EKG changes in the absence of anginal type symptoms. Lightheadedness and a blunted systolic blood pressure response to exercise. Brief Hospital Course: ___ woman with history seizure disorder and paroxysmal atrial fibrillation presenting with palpitations admitted for management of symptomatic a-fib without hemodynamic instability. # ATRIAL FIBRILLATION Initially presented for palpitations with history of paroxysmal a-fib. Discovered to be in continuous a-fib with RVR which was controlled with initiation of metoprolol. Did not convert back to sinus. Suspect precipitated by recent down-titration of clonazepam vs. newly discovered herpes zoster re-activation. Started anti-coagulation with apixaban. Monitored on telemetry with adequate rate control. Given her significant concern for how rhythm might affect exercise tolerance, underwent exercise stress which showed non-specific EKG changes in the absence of anginal type symptoms. The patient was noted to have a blunted systolic blood pressure response to exercise, so her metoprolol was downtitrated slightly. At discharge, she was switched to metoprolol succinate 62.5mg with good rate control and HRs <90s consistently. Discharged with plan to follow up with PCP and cardiologist. # HERPES ZOSTER REACTIVATION Reported new onset irritation of right back extending to right lateral breast. With new rash in dermatomal distribution most consistent with herpes zoster reactivation. Possibly contributed to persistent a-fib. Discharged on 7-day course valacyclovir. # HISTORY OF ABSENCE SEIZURES On arrival reported worsening seizure activity. Evaluated by neurology who found that her symptoms were adequately controlled and did not recommend any adjustments to AED regimen. No EEG was necessary. Stable at time of discharge. Continued home gabapentin and clonazepam. # BILATERAL WHEEZING # HISTORY OF ASTHMA Reports ongoing symptoms of wheezing unchanged for years. No labored breathing. Was not amenable to CXR. Respiratory status stable for duration of admission. TRANSITIONAL ISSUES ================================= [ ] Plan to complete 7-day course valacyclovir for herpes zoster re-activation. Last day ___. #CONTACT: ___ (husband: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5 mg PO QHS 2. Gabapentin 300 mg PO BID 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. Metoprolol Succinate XL 62.5 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. ValACYclovir 1000 mg PO Q8H RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 8 hours Disp #*21 Tablet Refills:*0 4. ClonazePAM 0.25 mg PO BID:PRN Anxiety RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. ClonazePAM 0.5 mg PO QHS 6. Gabapentin 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================================= # RAPID ATRIAL FIBRILLATION SECONDARY DIAGNOSES ================================= # HERPES ZOSTER REACTIVATION # HISTORY OF ABSENCE SEIZURES # BILATERAL WHEEZING # HISTORY OF ASTHMA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why you were in the hospital: - palpitations - irregular heart rhythm called atrial fibrillation What was done for you in the hospital: - We monitored your heart rhythm and gave you a new medication called metoprolol to help keep it at an appropriate rate. - We started you on a medication call apixaban to thin your blood and help prevent a stroke. - We performed and exercise stress test which showed your heart was functioning adequately despite this irregular rhythm. What you should do after you leave the hospital: - Please call the cardiology department at ___ to arrange for ___ of Hearts device to monitor your atrial fibrillation. You should call on ___ morning to arrange an appointment as soon as possible. - Please take your medications as detailed in the discharge papers. If you have questions about which medications to take, please contact your regular doctor to discuss. - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "I481", "G4089", "B029", "J45909", "N6459" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Vioxx / Motrin / phenobarbital / latex / gluten Chief Complaint: dizziness, dyspnea, palpitations Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with a history of paroxysmal Atrial fib presents with palpitations. She presented today with 12 hours of continuous palpitations and irregular heartbeat. She states she woke this morning and noticed that her heartbeat felt irregular. The feeling persisted throughout the day. She knew she was in Atrial Fibrillation. She has been having on and off palpitations for one month, usually only lasting one hour, but this did not resolve. She also reports a few days of dizziness, as well as DOE when walking up hills since [MASKED]. She has a history of wheezing due to asthma which is chronic. She denies any chest pain, orthopnea, leg swelling, weight gain, fever, chills, urinary symptoms, nausea, vomiting, diarrhea. She has noted some mild bilateral breast tenderness in the last [MASKED] days. Appetite has been poor. She is followed by Dr. [MASKED] cardiology and is not on anticoagulation. She previously avoided anticoagulation due to h/o absence seizures and fall concern. She says her seizures have been very well controlled for years, no fall for over [MASKED] years. She still has seizures daily but they are short lived. She is willing to be anticoagulated if clinically recommended. Past Medical History: Atrial fib/flutter, paroxysmal Cervical radiculopathy Asthma Celiac Sprue Osteopenia H/o seizures Vitamin D deficiency Allergic Rhinitis Spinal stenosis Hyperlipidemia Social History: [MASKED] Family History: - Grandfather with h/o MI in his [MASKED] - Father: heart murmur, cerebral aneurysm - Mother: irregular heart rate, hypertension, CVA age [MASKED], cerebral aneurysm Physical Exam: ADMISSION EXAM ========================== VS: 97.8, BP 108 / 73, HR 72, RR 17, 98 RA GENERAL: NAD, well appearing HEENT: AT/NC, anicteric sclera NECK: supple, no LAD HEART: Irregular, regular rate, no murmurs LUNGS: Bilateral end-expiratory wheezing equal on both sides, no rales, no resp distress GI: abdomen soft, nontender EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&O grossly, face symmetric, moving all extremities LYMPH: No axillary adenopathy SKIN: Skin tag in Right axilla DISCHARGE EXAM ========================== 24 HR Data (last updated [MASKED] @ 1411) Temp: 97.7 (Tm 98.3), BP: 96/64 (90-101/54 (manual)-67), HR: 77 (71-142), RR: 17 ([MASKED]), O2 sat: 96% (95-98), O2 delivery: Ra, Wt: 123.2 lb/55.88 kg GENERAL: Well appearing woman in no acute distress. Comfortable. NEURO: AAOx3. CNII-XII grossly intact. Strength [MASKED] in upper and lower extremities bilaterally. Sensation grossly intact. HEENT: NCAT. EOMI. MMM. CARDIAC: Irregular rhythm, normal rate. Normal S1/S2. No murmurs, rubs, or gallops. PULMONARY: Diffuse expiratory wheezing. Breathing comfortably on room air. ABDOMEN: Soft, non-tender, non-distended. BACK: [MASKED] erythematous papules along right back wrapping around to right mid-breast. EXTREMITIES: Warm, well perfused, non-edematous. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS ========================== [MASKED] 07:39PM BLOOD WBC-4.7 RBC-4.52 Hgb-14.5 Hct-43.6 MCV-97 MCH-32.1* MCHC-33.3 RDW-12.2 RDWSD-43.2 Plt [MASKED] [MASKED] 07:39PM BLOOD Neuts-63.1 [MASKED] Monos-7.4 Eos-2.3 Baso-0.4 Im [MASKED] AbsNeut-2.98 AbsLymp-1.26 AbsMono-0.35 AbsEos-0.11 AbsBaso-0.02 [MASKED] 07:39PM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-142 K-4.2 Cl-101 HCO3-27 AnGap-14 [MASKED] 07:39PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1 PERTINENT LABS ========================== [MASKED] 07:35AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-143 K-4.4 Cl-104 HCO3-29 AnGap-10 [MASKED] 07:39PM BLOOD cTropnT-<0.01 [MASKED] 02:00AM BLOOD cTropnT-<0.01 DISCHARGE LABS ========================== [MASKED] 07:35AM BLOOD WBC-4.0 RBC-4.53 Hgb-14.4 Hct-43.7 MCV-97 MCH-31.8 MCHC-33.0 RDW-11.9 RDWSD-42.1 Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-143 K-4.4 Cl-104 HCO3-29 AnGap-10 [MASKED] 07:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 PERTINENT STUDIES ========================== TTE ([MASKED]) Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. STRESS EKG ([MASKED]/) Non-specific EKG changes in the absence of anginal type symptoms. Lightheadedness and a blunted systolic blood pressure response to exercise. Brief Hospital Course: [MASKED] woman with history seizure disorder and paroxysmal atrial fibrillation presenting with palpitations admitted for management of symptomatic a-fib without hemodynamic instability. # ATRIAL FIBRILLATION Initially presented for palpitations with history of paroxysmal a-fib. Discovered to be in continuous a-fib with RVR which was controlled with initiation of metoprolol. Did not convert back to sinus. Suspect precipitated by recent down-titration of clonazepam vs. newly discovered herpes zoster re-activation. Started anti-coagulation with apixaban. Monitored on telemetry with adequate rate control. Given her significant concern for how rhythm might affect exercise tolerance, underwent exercise stress which showed non-specific EKG changes in the absence of anginal type symptoms. The patient was noted to have a blunted systolic blood pressure response to exercise, so her metoprolol was downtitrated slightly. At discharge, she was switched to metoprolol succinate 62.5mg with good rate control and HRs <90s consistently. Discharged with plan to follow up with PCP and cardiologist. # HERPES ZOSTER REACTIVATION Reported new onset irritation of right back extending to right lateral breast. With new rash in dermatomal distribution most consistent with herpes zoster reactivation. Possibly contributed to persistent a-fib. Discharged on 7-day course valacyclovir. # HISTORY OF ABSENCE SEIZURES On arrival reported worsening seizure activity. Evaluated by neurology who found that her symptoms were adequately controlled and did not recommend any adjustments to AED regimen. No EEG was necessary. Stable at time of discharge. Continued home gabapentin and clonazepam. # BILATERAL WHEEZING # HISTORY OF ASTHMA Reports ongoing symptoms of wheezing unchanged for years. No labored breathing. Was not amenable to CXR. Respiratory status stable for duration of admission. TRANSITIONAL ISSUES ================================= [ ] Plan to complete 7-day course valacyclovir for herpes zoster re-activation. Last day [MASKED]. #CONTACT: [MASKED] (husband: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5 mg PO QHS 2. Gabapentin 300 mg PO BID 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. Metoprolol Succinate XL 62.5 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. ValACYclovir 1000 mg PO Q8H RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 8 hours Disp #*21 Tablet Refills:*0 4. ClonazePAM 0.25 mg PO BID:PRN Anxiety RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. ClonazePAM 0.5 mg PO QHS 6. Gabapentin 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================================= # RAPID ATRIAL FIBRILLATION SECONDARY DIAGNOSES ================================= # HERPES ZOSTER REACTIVATION # HISTORY OF ABSENCE SEIZURES # BILATERAL WHEEZING # HISTORY OF ASTHMA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. Why you were in the hospital: - palpitations - irregular heart rhythm called atrial fibrillation What was done for you in the hospital: - We monitored your heart rhythm and gave you a new medication called metoprolol to help keep it at an appropriate rate. - We started you on a medication call apixaban to thin your blood and help prevent a stroke. - We performed and exercise stress test which showed your heart was functioning adequately despite this irregular rhythm. What you should do after you leave the hospital: - Please call the cardiology department at [MASKED] to arrange for [MASKED] of Hearts device to monitor your atrial fibrillation. You should call on [MASKED] morning to arrange an appointment as soon as possible. - Please take your medications as detailed in the discharge papers. If you have questions about which medications to take, please contact your regular doctor to discuss. - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in [MASKED] business days, please contact the office to schedule an appointment. - Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "J45909" ]
[ "I481: Persistent atrial fibrillation", "G4089: Other seizures", "B029: Zoster without complications", "J45909: Unspecified asthma, uncomplicated", "N6459: Other signs and symptoms in breast" ]
10,061,303
24,889,301
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement (27 Epic) ___ History of Present Illness: ___ man with a h/o HTN, DLD, DM , AI/AS and non-ischemic cardiomyopathy (possibly alcohol induced). ___ positive for palpitations, increased fatigue and shortness of breath. He denies chest pain, PND, or GI symptoms. ECHO ___ revealed progression of significant left ventricular dysfunction. Stress echo demonstrated no ischemic changes. Cardiac cath today revealed 40-50% obstruction of circumflex, 30% RCA mid, and LAD with mild luminal narrowing per Dr. ___ has a significant history of gastric ulcer s/p partial gastrectomy 40 plus years ago. ___ does not take ASA because of this. He is being evaluated today for surgical intervention for AVR by Dr. ___. Past Medical History: Anemia Psoriasis Hypothyroidism Hx of iron deficiency anemia with normal ferritin ___ Diverticulosis Gastric ulcer s/p partial gastrectomy Pulmonary nodules/lesions, multiple Aortic valve insufficiency Cardiomyopathy, nonischemic erectile dysfunction Obesity Colon polyp Rotator cuff tear Diabetes type 2, controlled Hyperlipidemia Chronic systolic HF (heart failure) Aortic stenosis Hypertension Hypertriglyceridemia Diabetes mellitus type 2 without retinopathy Right rotor cuff repair (___) Social History: ___ Family History: BrotherDiabetes ___ at age ___ Hypertension; Stroke ___ - Type I Physical Exam: Pulse: 82 Resp: 20 O2 sat: 98 RA B/P Right: 125/77 Left: 156/70 Height: 69.5 inches Wt: 223 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [] _____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:2+ Left:2+ Radial Right:2+ Left:2+ Pertinent Results: ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ TEE (Complete) Done ___ at 8:55:49 AM PRELIMINARY Referring Physician ___ ___. ___ - Division of Cardiot___ Status: Inpatient DOB: ___ Age (years): ___ M Hgt (in): 70 BP (mm Hg): 167/68 Wgt (lb): 223 HR (bpm): 64 BSA (m2): 2.19 m2 Indication: Abnormal ECG. Aortic valve disease. Diagnosis: I35.9 ___ Information Date/Time: ___ at 08:55 ___ MD: ___, MD ___ Type: TEE (Complete) Sonographer: ___, MD Doppler: Full Doppler and color Doppler ___ Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Machine: Echocardiographic Measurements Results Measurements Normal Range Aorta - Ascending: *4.7 cm <= 3.4 cm Findings LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aorta at sinus level. Mildly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Minimal AS. Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. ___ VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: Written informed consent was obtained from the ___. No TEE related complications. The TEE probe was not passed beyond the mid-esophagus. Conclusions Pre-bypass: The left atrium is normal in size. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). The LV is mildly dialted.Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level (4.8cm). The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic annulus measured 29mm. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. By planimetry ___ 2.2cm2. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Due to gastrectomy history, probe not advanced past mid-esophagus. Post-bypass: on phenylephrine gtt, epinephrine gtt LVEF 45%, ___ well seated without PVL, 29mm bioprosthetic valve. Valve gradients not measured due to gastrectomy and non-passage of probe passed mid esophageal position. . ___ 06:50AM BLOOD WBC-6.4 RBC-4.36* Hgb-12.0* Hct-38.2* MCV-88 MCH-27.5 MCHC-31.4* RDW-13.6 RDWSD-43.5 Plt ___ ___ 05:42AM BLOOD WBC-12.1* RBC-4.29* Hgb-11.8* Hct-36.8* MCV-86 MCH-27.5 MCHC-32.1 RDW-13.9 RDWSD-43.1 Plt Ct-92* ___ 06:50AM BLOOD ___ ___ 05:27AM BLOOD ___ ___ 06:50AM BLOOD Glucose-117* UreaN-19 Creat-0.9 Na-139 K-4.5 Cl-103 ___ 06:20AM BLOOD Glucose-133* UreaN-21* Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-24 AnGap-15 ___ 06:50AM BLOOD Phos-3.9 Mg-1.9 Brief Hospital Course: The ___ was brought to the Operating Room on ___ where the ___ underwent AVR (27 Epic tissue) with Dr. ___. Overall the ___ tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the ___ extubated, alert and oriented and breathing comfortably. The ___ was neurologically intact and hemodynamically stable. Beta blocker was initiated and the ___ was gently diuresed toward the preoperative weight. He developed AFib and also vacillated w junctional rhythm. EP was consulted. Coumadin initiated and beta blocker discontinued. The ___ was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The ___ was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the ___ was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The ___ was discharged home in good condition with appropriate follow up instructions. Anti-coagulation will be managed via the ___ clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Ketoconazole 2% 1 Appl TP DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Sildenafil 20 mg PO DAILY:PRN ED 7. Simvastatin 20 mg PO QPM 8. Valsartan 80 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Aspirin EC 81 mg PO DAILY RX *aspirin [Aspir-Low] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 4. Warfarin 2.5 mg PO DAILY16 Dose to change daily per ___ clinic for goal INR ___, dx: AFib RX *warfarin 2.5 mg ___ tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*1 6. Valsartan 20 mg PO DAILY RX *valsartan 40 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 7. Furosemide 20 mg PO DAILY 8. Ketoconazole 2% 1 Appl TP DAILY 9. Levothyroxine Sodium 100 mcg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Simvastatin 20 mg PO QPM 12. HELD- Sildenafil 20 mg PO DAILY:PRN ED This medication was held. Do not restart Sildenafil until discussed with PCP ___: Home With Service Facility: ___ Discharge Diagnosis: aortic insufficiency . Anemia Psoriasis Hypothyroidism Hx of iron deficiency anemia with normal ferritin ___ Diverticulosis Gastric ulcer s/p partial gastrectomy Pulmonary nodules/lesions, multiple Aortic valve insufficiency Cardiomyopathy, nonischemic erectile dysfunction Obesity Colon polyp Rotator cuff tear Diabetes type 2, controlled Hyperlipidemia Chronic systolic HF (heart failure) Aortic stenosis Hypertension Hypertriglyceridemia Diabetes mellitus type 2 without retinopathy Past Surgical History: Right rotor cuff repair (___) Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Followup Instructions: ___
[ "I352", "I426", "I110", "I5022", "I4891", "E119", "D509", "I2510", "Z7901", "E785", "F1021", "E039", "E669", "Z6832", "Z87891", "Z23", "N529" ]
Allergies: All allergies / adverse drug reactions previously recorded have been deleted Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement (27 Epic) [MASKED] History of Present Illness: [MASKED] man with a h/o HTN, DLD, DM , AI/AS and non-ischemic cardiomyopathy (possibly alcohol induced). [MASKED] positive for palpitations, increased fatigue and shortness of breath. He denies chest pain, PND, or GI symptoms. ECHO [MASKED] revealed progression of significant left ventricular dysfunction. Stress echo demonstrated no ischemic changes. Cardiac cath today revealed 40-50% obstruction of circumflex, 30% RCA mid, and LAD with mild luminal narrowing per Dr. [MASKED] has a significant history of gastric ulcer s/p partial gastrectomy 40 plus years ago. [MASKED] does not take ASA because of this. He is being evaluated today for surgical intervention for AVR by Dr. [MASKED]. Past Medical History: Anemia Psoriasis Hypothyroidism Hx of iron deficiency anemia with normal ferritin [MASKED] Diverticulosis Gastric ulcer s/p partial gastrectomy Pulmonary nodules/lesions, multiple Aortic valve insufficiency Cardiomyopathy, nonischemic erectile dysfunction Obesity Colon polyp Rotator cuff tear Diabetes type 2, controlled Hyperlipidemia Chronic systolic HF (heart failure) Aortic stenosis Hypertension Hypertriglyceridemia Diabetes mellitus type 2 without retinopathy Right rotor cuff repair ([MASKED]) Social History: [MASKED] Family History: BrotherDiabetes [MASKED] at age [MASKED] Hypertension; Stroke [MASKED] - Type I Physical Exam: Pulse: 82 Resp: 20 O2 sat: 98 RA B/P Right: 125/77 Left: 156/70 Height: 69.5 inches Wt: 223 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [X] non-distended [X] non-tender [] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [] [MASKED] Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ [MASKED] Right:2+ Left:2+ Radial Right:2+ Left:2+ Pertinent Results: [MASKED] ECHOCARDIOGRAPHY REPORT [MASKED] [MASKED] MRN: [MASKED] TEE (Complete) Done [MASKED] at 8:55:49 AM PRELIMINARY Referring Physician [MASKED] [MASKED]. [MASKED] - Division of Cardiot Status: Inpatient DOB: [MASKED] Age (years): [MASKED] M Hgt (in): 70 BP (mm Hg): 167/68 Wgt (lb): 223 HR (bpm): 64 BSA (m2): 2.19 m2 Indication: Abnormal ECG. Aortic valve disease. Diagnosis: I35.9 [MASKED] Information Date/Time: [MASKED] at 08:55 [MASKED] MD: [MASKED], MD [MASKED] Type: TEE (Complete) Sonographer: [MASKED], MD Doppler: Full Doppler and color Doppler [MASKED] Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Machine: Echocardiographic Measurements Results Measurements Normal Range Aorta - Ascending: *4.7 cm <= 3.4 cm Findings LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aorta at sinus level. Mildly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Minimal AS. Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. GENERAL COMMENTS: Written informed consent was obtained from the [MASKED]. No TEE related complications. The TEE probe was not passed beyond the mid-esophagus. Conclusions Pre-bypass: The left atrium is normal in size. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). The LV is mildly dialted.Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level (4.8cm). The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic annulus measured 29mm. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. By planimetry [MASKED] 2.2cm2. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Due to gastrectomy history, probe not advanced past mid-esophagus. Post-bypass: on phenylephrine gtt, epinephrine gtt LVEF 45%, [MASKED] well seated without PVL, 29mm bioprosthetic valve. Valve gradients not measured due to gastrectomy and non-passage of probe passed mid esophageal position. . [MASKED] 06:50AM BLOOD WBC-6.4 RBC-4.36* Hgb-12.0* Hct-38.2* MCV-88 MCH-27.5 MCHC-31.4* RDW-13.6 RDWSD-43.5 Plt [MASKED] [MASKED] 05:42AM BLOOD WBC-12.1* RBC-4.29* Hgb-11.8* Hct-36.8* MCV-86 MCH-27.5 MCHC-32.1 RDW-13.9 RDWSD-43.1 Plt Ct-92* [MASKED] 06:50AM BLOOD [MASKED] [MASKED] 05:27AM BLOOD [MASKED] [MASKED] 06:50AM BLOOD Glucose-117* UreaN-19 Creat-0.9 Na-139 K-4.5 Cl-103 [MASKED] 06:20AM BLOOD Glucose-133* UreaN-21* Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-24 AnGap-15 [MASKED] 06:50AM BLOOD Phos-3.9 Mg-1.9 Brief Hospital Course: The [MASKED] was brought to the Operating Room on [MASKED] where the [MASKED] underwent AVR (27 Epic tissue) with Dr. [MASKED]. Overall the [MASKED] tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the [MASKED] extubated, alert and oriented and breathing comfortably. The [MASKED] was neurologically intact and hemodynamically stable. Beta blocker was initiated and the [MASKED] was gently diuresed toward the preoperative weight. He developed AFib and also vacillated w junctional rhythm. EP was consulted. Coumadin initiated and beta blocker discontinued. The [MASKED] was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The [MASKED] was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the [MASKED] was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The [MASKED] was discharged home in good condition with appropriate follow up instructions. Anti-coagulation will be managed via the [MASKED] clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Ketoconazole 2% 1 Appl TP DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Sildenafil 20 mg PO DAILY:PRN ED 7. Simvastatin 20 mg PO QPM 8. Valsartan 80 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Aspirin EC 81 mg PO DAILY RX *aspirin [Aspir-Low] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 4. Warfarin 2.5 mg PO DAILY16 Dose to change daily per [MASKED] clinic for goal INR [MASKED], dx: AFib RX *warfarin 2.5 mg [MASKED] tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*1 6. Valsartan 20 mg PO DAILY RX *valsartan 40 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 7. Furosemide 20 mg PO DAILY 8. Ketoconazole 2% 1 Appl TP DAILY 9. Levothyroxine Sodium 100 mcg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Simvastatin 20 mg PO QPM 12. HELD- Sildenafil 20 mg PO DAILY:PRN ED This medication was held. Do not restart Sildenafil until discussed with PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: aortic insufficiency . Anemia Psoriasis Hypothyroidism Hx of iron deficiency anemia with normal ferritin [MASKED] Diverticulosis Gastric ulcer s/p partial gastrectomy Pulmonary nodules/lesions, multiple Aortic valve insufficiency Cardiomyopathy, nonischemic erectile dysfunction Obesity Colon polyp Rotator cuff tear Diabetes type 2, controlled Hyperlipidemia Chronic systolic HF (heart failure) Aortic stenosis Hypertension Hypertriglyceridemia Diabetes mellitus type 2 without retinopathy Past Surgical History: Right rotor cuff repair ([MASKED]) Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Followup Instructions: [MASKED]
[]
[ "I110", "I4891", "E119", "D509", "I2510", "Z7901", "E785", "E039", "E669", "Z87891" ]
[ "I352: Nonrheumatic aortic (valve) stenosis with insufficiency", "I426: Alcoholic cardiomyopathy", "I110: Hypertensive heart disease with heart failure", "I5022: Chronic systolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "F1021: Alcohol dependence, in remission", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "Z87891: Personal history of nicotine dependence", "Z23: Encounter for immunization", "N529: Male erectile dysfunction, unspecified" ]
10,061,633
29,357,112
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue Major Surgical or Invasive Procedure: ___: Mitral valve repair with a resection of the middle scallop of the posterior leaflet P2 and mitral valve annuloplasty with a 30 ___ annuloplasty band. History of Present Illness: Mr. ___ is a ___ year old male with known mitral regurgitation. Overall, he reports he is doing well. He remains active as a ___ of mushrooms. He denies any associated chest pain, dyspnea, or other concerning symptoms. He continues to be very active, walking several miles a day, lifting several 20lbs packs of mushrooms, carrying them for ___ hours at a time. He denies fever, chills, weight gain or loss,nausea or diarrhea, chest pain or pressure, shortness of breath, nocturnal dyspnea, peripheral edema, calf or buttocks pain and the remainder of a comprehensive review of systems is negative in detail. His most recent echocardiogram showed findings consistent with partial posterior leaflet flail with severe mitral regurgitation and mild pulmonary hypertension. Given echo findings, he was referred for surgical evaluation. He has noted increased fatigue but denied shortness of breath, dyspnea on exertion, chest pain, palpitations, leg edema, dizziness, or syncope. Of note, he had 3rd degree burns over 65% of his body back in ___ including his chest. Has history of chronic anemia and has been evaluated by hematology and found to be B12 deficient secondary to atrophic gastritis. Initially evaluated by Dr. ___ in ___, additional workup was recommended. He presents today to discuss findings and likely schedule surgery. He may also require hematology clearance given history of hypogammagobulinemia and anemia. Angiogram was found to be normal and MV had 3+ MR with Partial posterior leaflet flail. He is now scheduled for surgery on ___. Past Medical History: Anemia secondary to Atrophic Gastritis Burns, extensive including chest Deep Vein Thrombosis s/p IVC Filter Hypogammagobulinemia Hypothyroidism Mitral Regurgitation Mitral Valve Prolapse Social History: ___ Family History: No mitral valve or coronary artery disease Mother - polycythemia ___ ___ Exam: Vital Signs sheet entries for ___: BP: 133/73 Heart Rate: 66 O2 Saturation%: 99% Resp. Rate: 20. Pain Score: 0. Height: 69 in Weight: 139 lbs General: Skin: Dry [x] intact [x] HEENT: PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade ___ SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: ___ Right: + Left:+ Radial Right: wrist splint Left:X Carotid Bruit: Right: - Left: - . Discharge Exam: 98.1 PO 122 / 78 L Sitting 73 16 97 Ra / General: NAD Neurological: A/O x3 limited ROM UE states that it is almost back to baseline Cardiovascular: RRR no murmur or rub Respiratory: Clear Decreased at bases No resp distress GI/Abdomen: Bowel sounds present Soft ND NT Extremities: Right Upper extremity Warm Edema +1 with home wrap Left Upper extremity Warm Edema trace Right Lower extremity Warm Edema +1 chronic skin changes resulting from burns Left Lower extremity Warm Edema +1 chronic skin changes resulting from burns changes Skin/Wounds: Unchanged burn scars Sternal: CDI no erythema or drainage Sternum stable Pertinent Results: Transesophageal Echocardiogram ___ PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium (LA)/Pulmonary Veins: Dilated LA. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): DIlated RA. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Moderate symmetric hypertrophy. Normal cavity size. Normal regional & global systolic function Normal ejection fraction. Intrinsic LVEF likely lower due to severity of mitral regurgitation. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Normal descending aorta diameter. No aortic coarcation. No dissection. Focal calcifications in the sinus. No ascending atheroma. Simple arch atheroma. Simple descending atheroma. PULMONARY ARTERY: Dilated main pulmonary artery. Aortic Valve: Thin/mobile (3) leaflets. No stenosis. Trace regurgitation. Mitral Valve: Moderately thickened leaflets. Flail leaflet. No stenosis. SEVERE [4+] regurgitation. Eccentric, anteriorly directed jet. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. Central jet. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 14:11:00. Sinus rhythm. Post-op Comments cardiac output 4 LPM by continuity just prior to chest closure. Support: Vasopressor(s): none. Left Ventricle: Similar to preoperative findings. Similar regional function. Global ejection fraction is normal. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. Unchanged gradient. No change in aortic regurgitation. Mitral Valve: Annular ring. Post-bypass, mean mitral valve gradient = 2mmHg. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. . ___ 06:00AM BLOOD WBC-5.9 RBC-3.50* Hgb-9.7* Hct-30.0* MCV-86 MCH-27.7 MCHC-32.3 RDW-16.1* RDWSD-50.2* Plt ___ ___ 06:49AM BLOOD ___ ___ 06:00AM BLOOD Glucose-103* UreaN-15 Creat-0.7 Na-141 K-4.1 Cl-101 HCO3-30 AnGap-10 ___ 06:00AM BLOOD Mg-2.0 Brief Hospital Course: He was admitted on ___ and was taken to the operating room. He underwent mitral valve repair. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated on later that evening. Beta blocker was initiated and he was diuresed toward his preoperative weight. A PICC line was placed for access. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. terbinafine HCl 250 mg oral DAILY 4. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Ibuprofen Dose is Unknown PO Frequency is Unknown 7. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown 8. Vitamin E Dose is Unknown PO Frequency is Unknown 9. Probiotic 4X (B.infantis-B.ani-B.long-B.bifi) ___ mg oral unknown 10. herbal drugs oral unknown Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ascorbic Acid ___ mg PO DAILY RX *ascorbic acid (vitamin C) [C-1000] 1,000 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Cyanocobalamin 500 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 5. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 6. GuaiFENesin ER 1200 mg PO Q12H Duration: 5 Days RX *guaifenesin [Mucus Relief ER] 1,200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 7. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 packet(s) by mouth once a day Disp #*7 Tablet Refills:*0 9. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 11. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild 12. Vitamin E 400 UNIT PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU BID 15. terbinafine HCl 250 mg oral DAILY 16. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 17. HELD- Cholestyramine Light (cholestyramine-aspartame) 4 gram oral DAILY This medication was held. Do not restart Cholestyramine Light until directed by PCP 18. HELD- Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown This medication was held. Do not restart Fish Oil (Omega 3) until directed by PCP 19. HELD- herbal drugs oral unknown This medication was held. Do not restart herbal drugs until directed by PCP 20. HELD- Probiotic 4X (B.infantis-B.ani-B.long-B.bifi) ___ mg oral unknown This medication was held. Do not restart Probiotic 4X until directed by PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Mitral Regurgitation . - Mitral valve prolapse/severe mitral regurgitation. - Extensive burns years ago. - Hypogammagobulinemia: worked up by hematology with bone marrow bx and found there is no hematologic source. ___ - Hypothyroidism - Anemia secondary to atrophic gastritis Past Surgical History: appy multiple surgeries (for skin grafts and upper body contractures )from severe burns R hernia Sx Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Staples- *to be discontinued at wound check appointment ___ Trace edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I340", "I511", "D801", "F05", "D62", "I2720", "D519", "Z86718", "E039", "Z781", "Y831", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [MASKED]: Mitral valve repair with a resection of the middle scallop of the posterior leaflet P2 and mitral valve annuloplasty with a 30 [MASKED] annuloplasty band. History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with known mitral regurgitation. Overall, he reports he is doing well. He remains active as a [MASKED] of mushrooms. He denies any associated chest pain, dyspnea, or other concerning symptoms. He continues to be very active, walking several miles a day, lifting several 20lbs packs of mushrooms, carrying them for [MASKED] hours at a time. He denies fever, chills, weight gain or loss,nausea or diarrhea, chest pain or pressure, shortness of breath, nocturnal dyspnea, peripheral edema, calf or buttocks pain and the remainder of a comprehensive review of systems is negative in detail. His most recent echocardiogram showed findings consistent with partial posterior leaflet flail with severe mitral regurgitation and mild pulmonary hypertension. Given echo findings, he was referred for surgical evaluation. He has noted increased fatigue but denied shortness of breath, dyspnea on exertion, chest pain, palpitations, leg edema, dizziness, or syncope. Of note, he had 3rd degree burns over 65% of his body back in [MASKED] including his chest. Has history of chronic anemia and has been evaluated by hematology and found to be B12 deficient secondary to atrophic gastritis. Initially evaluated by Dr. [MASKED] in [MASKED], additional workup was recommended. He presents today to discuss findings and likely schedule surgery. He may also require hematology clearance given history of hypogammagobulinemia and anemia. Angiogram was found to be normal and MV had 3+ MR with Partial posterior leaflet flail. He is now scheduled for surgery on [MASKED]. Past Medical History: Anemia secondary to Atrophic Gastritis Burns, extensive including chest Deep Vein Thrombosis s/p IVC Filter Hypogammagobulinemia Hypothyroidism Mitral Regurgitation Mitral Valve Prolapse Social History: [MASKED] Family History: No mitral valve or coronary artery disease Mother - polycythemia [MASKED] [MASKED] Exam: Vital Signs sheet entries for [MASKED]: BP: 133/73 Heart Rate: 66 O2 Saturation%: 99% Resp. Rate: 20. Pain Score: 0. Height: 69 in Weight: 139 lbs General: Skin: Dry [x] intact [x] HEENT: PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade [MASKED] SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: [MASKED] Right: + Left:+ Radial Right: wrist splint Left:X Carotid Bruit: Right: - Left: - . Discharge Exam: 98.1 PO 122 / 78 L Sitting 73 16 97 Ra / General: NAD Neurological: A/O x3 limited ROM UE states that it is almost back to baseline Cardiovascular: RRR no murmur or rub Respiratory: Clear Decreased at bases No resp distress GI/Abdomen: Bowel sounds present Soft ND NT Extremities: Right Upper extremity Warm Edema +1 with home wrap Left Upper extremity Warm Edema trace Right Lower extremity Warm Edema +1 chronic skin changes resulting from burns Left Lower extremity Warm Edema +1 chronic skin changes resulting from burns changes Skin/Wounds: Unchanged burn scars Sternal: CDI no erythema or drainage Sternum stable Pertinent Results: Transesophageal Echocardiogram [MASKED] PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium (LA)/Pulmonary Veins: Dilated LA. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): DIlated RA. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Moderate symmetric hypertrophy. Normal cavity size. Normal regional & global systolic function Normal ejection fraction. Intrinsic LVEF likely lower due to severity of mitral regurgitation. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Normal descending aorta diameter. No aortic coarcation. No dissection. Focal calcifications in the sinus. No ascending atheroma. Simple arch atheroma. Simple descending atheroma. PULMONARY ARTERY: Dilated main pulmonary artery. Aortic Valve: Thin/mobile (3) leaflets. No stenosis. Trace regurgitation. Mitral Valve: Moderately thickened leaflets. Flail leaflet. No stenosis. SEVERE [4+] regurgitation. Eccentric, anteriorly directed jet. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. Central jet. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 14:11:00. Sinus rhythm. Post-op Comments cardiac output 4 LPM by continuity just prior to chest closure. Support: Vasopressor(s): none. Left Ventricle: Similar to preoperative findings. Similar regional function. Global ejection fraction is normal. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. Unchanged gradient. No change in aortic regurgitation. Mitral Valve: Annular ring. Post-bypass, mean mitral valve gradient = 2mmHg. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. . [MASKED] 06:00AM BLOOD WBC-5.9 RBC-3.50* Hgb-9.7* Hct-30.0* MCV-86 MCH-27.7 MCHC-32.3 RDW-16.1* RDWSD-50.2* Plt [MASKED] [MASKED] 06:49AM BLOOD [MASKED] [MASKED] 06:00AM BLOOD Glucose-103* UreaN-15 Creat-0.7 Na-141 K-4.1 Cl-101 HCO3-30 AnGap-10 [MASKED] 06:00AM BLOOD Mg-2.0 Brief Hospital Course: He was admitted on [MASKED] and was taken to the operating room. He underwent mitral valve repair. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated on later that evening. Beta blocker was initiated and he was diuresed toward his preoperative weight. A PICC line was placed for access. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. terbinafine HCl 250 mg oral DAILY 4. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Ibuprofen Dose is Unknown PO Frequency is Unknown 7. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown 8. Vitamin E Dose is Unknown PO Frequency is Unknown 9. Probiotic 4X (B.infantis-B.ani-B.long-B.bifi) [MASKED] mg oral unknown 10. herbal drugs oral unknown Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ascorbic Acid [MASKED] mg PO DAILY RX *ascorbic acid (vitamin C) [C-1000] 1,000 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Cyanocobalamin 500 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 5. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 6. GuaiFENesin ER 1200 mg PO Q12H Duration: 5 Days RX *guaifenesin [Mucus Relief ER] 1,200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 7. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 packet(s) by mouth once a day Disp #*7 Tablet Refills:*0 9. Ranitidine 150 mg PO DAILY RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 11. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild 12. Vitamin E 400 UNIT PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU BID 15. terbinafine HCl 250 mg oral DAILY 16. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 17. HELD- Cholestyramine Light (cholestyramine-aspartame) 4 gram oral DAILY This medication was held. Do not restart Cholestyramine Light until directed by PCP 18. HELD- Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown This medication was held. Do not restart Fish Oil (Omega 3) until directed by PCP 19. HELD- herbal drugs oral unknown This medication was held. Do not restart herbal drugs until directed by PCP 20. HELD- Probiotic 4X (B.infantis-B.ani-B.long-B.bifi) [MASKED] mg oral unknown This medication was held. Do not restart Probiotic 4X until directed by PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: Mitral Regurgitation . - Mitral valve prolapse/severe mitral regurgitation. - Extensive burns years ago. - Hypogammagobulinemia: worked up by hematology with bone marrow bx and found there is no hematologic source. [MASKED] - Hypothyroidism - Anemia secondary to atrophic gastritis Past Surgical History: appy multiple surgeries (for skin grafts and upper body contractures )from severe burns R hernia Sx Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Staples- *to be discontinued at wound check appointment [MASKED] Trace edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "D62", "Z86718", "E039" ]
[ "I340: Nonrheumatic mitral (valve) insufficiency", "I511: Rupture of chordae tendineae, not elsewhere classified", "D801: Nonfamilial hypogammaglobulinemia", "F05: Delirium due to known physiological condition", "D62: Acute posthemorrhagic anemia", "I2720: Pulmonary hypertension, unspecified", "D519: Vitamin B12 deficiency anemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "E039: Hypothyroidism, unspecified", "Z781: Physical restraint status", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,061,677
25,475,802
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ultram / Morphine / Tegretol / Thioridazine / Penicillins / nickel / Haldol / doxycycline / amitriptyline / nortriptyline / ketorolac / amoxicillin / azithromycin / Bactrim / erythromycin base / carbamazepine / Vicodin / Valium / codeine / tetracycline / clindamycin / Elavil / trazodone / tramadol / quetiapine Attending: ___. Chief Complaint: Knee pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HTN, DM, MDD w/ complex psychiatric history presented to the ED on ___ for R knee pain. Patient stated he experienced injury to the knee while being restrained during recent psychiatric inpatient hospitalization at ___ approximately 2 weeks ago. He describes that he was "chop-blocked" while being restrained during his last psychiatric stay. Injury represented force to external aspect of the knee with medial and internal rotation thereafter. Patient was discharged from ___ on ___. Following discharge, he required wheel chair thereafter for approximately one week, however experienced gradual improvement to the point that he was able to ambulate with a cane. Patient is prescribed oxycodone for his pre-existing left arm injury and has been using that to medicate the RLE injury without relief. His ROS is otherwise notable for active suicidal ideation since discharge as well as continued pain in his existing left forearm injury. In the ED, initial vitals were: T: 97.1; HR: 74; BP: 121/73; RR: 16; PO2: 97% Exam was notable for: "R knee erythema, edema, tenderness to touch, pain with rom, ___ strength L anterior wrist wound down to sub q fat, no purulent drainage, limited wrist rom and strength" Labs were notable for: CRP: 6.1; Hemoglobin: 13.3. U Tox positive for oxycodone (known home medication) Studies were notable for: Knee X-ray: "No fracture. Probable small suprapatellar effusion. Sclerotic regions in the distal right femur and proximal right tibia likely prior infarcts as seen previously." The patient was evaluated by orthopedics and hand service for knee and hand injuries respectively. Recommended activity as tolerated for knee and follow up in sports medicine clinic in ___ weeks. Hand injury was most consistent with wound dehiscence that did not require inpatient intervention. Patient was additionally evaluated by psychiatry and deemed to meet ___ criteria. Patient remained in emergency department from ___ in the setting of an ongoing search for inpatient psychiatry care. During this time, he was continued on home doxepine 100/fluoxetine ___ m and Ativan PO PRN. He did not require chemical sedation while in the emergency department. He was admitted to medicine pending psychiatric placement On arrival to the floor, endorses the above history. He is continuing to experience severe pain in both the arm and leg. He endorses ongoing SI however states "he does not wish to talk about it". Past Medical History: - Depression with prior SI/HI - HTN - DM - Seizure disorder, not on medications - GI bleed ___ - Left flexor tendon repair (___ ___ - Diabetes Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Notable for 1+ edema in bilateral lower extremities, R>L. Non-tender, non-erythematous. R knee with erythema and edema. Tender to palpation with limited flexion/extension of joint. Left anterior wrist bandaged but partial visualization notable for deep tissue injury with exposed subcutaneous tissue but no obvious purulence SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== GENERAL: Alert, lying in bed. HEENT: Normocephalic, atraumatic. EOMI. LUNGS: No increased work of breathing on RA. Neuro: Alert, oriented, face symmetric. Pertinent Results: ADMISSION LABS: =============== ___ 07:57PM BLOOD WBC-5.6 RBC-5.53 Hgb-13.3* Hct-43.9 MCV-79* MCH-24.1* MCHC-30.3* RDW-14.4 RDWSD-41.1 Plt ___ ___ 07:57PM BLOOD Neuts-53.0 ___ Monos-5.0 Eos-1.3 Baso-0.5 Im ___ AbsNeut-2.94 AbsLymp-2.21 AbsMono-0.28 AbsEos-0.07 AbsBaso-0.03 ___ 07:57PM BLOOD Plt ___ ___ 07:57PM BLOOD CRP-6.1* ___ 04:10PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 04:10PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 04:10PM URINE RBC-4* WBC-4 Bacteri-FEW* Yeast-NONE Epi-0 ___ 04:10PM URINE Hours-RANDOM ___ 04:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG DISCHARGE LABS: =============== None MICROBIOLOGY: ============= ___ 4:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== ___ Knee X-Ray: IMPRESSION: No fracture. Probable small suprapatellar effusion. Sclerotic regions in the distal right femur and proximal right tibia likely prior infarcts as seen previously. Brief Hospital Course: BRIEF HOSPITAL COURSE ===================== ___ with history of HTN, DM, MDD w/ complex psychiatric history presented to the ED on ___ for R knee pain i/s/o recent trauma deemed not to require acute intervention by orthopedics, however, admitted to medicine for active SI pending inpatient psychiatric placement. While awaiting placement patient's vitals and labs were monitored as patient allowed. He was noted to be hyperglycemic on admission and insulin was restarted. He was treated with 30 units of Lantus at lunchtime and a Humalog sliding scale in addition to home metformin. Psychiatry team followed while patient was admitted and assisted with management. Patient was having persistent knee pain from an injury sustained while at a prior psychiatric facility. This was evaluated by orthopedics in the emergency department and the recommendations were for weight bearing as tolerated and conservative pain management. There was no indication for further imaging from their perspective. Due to persistent, severe, knee pain orthopedics was called to re-evaluate while patient was admitted. They felt that while his exam was likely consistent with a meniscus tear that there was stil lno indication for further imaging and that his pain was being appropriately managed at that time. As hospitalization progressed patient began to engage in less and less of the medical care and psychiatric evaluation attempting to be provided. Eventually, after repeat psychiatric evaluation decision was made to discharge him to home as he appears to be at his baseline mental health state and despite being at a chronically elevated risk for self harm it was felt that inpatient psychiatric hospitalization was unlikely to be helpful. Prior to discharge social work saw patient and provided him with information regarding outpatient partial programs for further treatment. TRANSITIONAL ISSUES: ==================== – Ongoing titration of patient's diabetic regimen. Discharged on 30u Lantus QHS, Metformin 500mg BID. Would benefit from further education regarding importance of compliance with antihyperglycemic therapy. - Follow up appointments: PCP, ___, Hand Surgery - Attempted to provide patient with refills for all new and continued chronic medications prior to discharge. He declined these medications but was provided prescriptions at discharge -SI: patient with intermittent ongoing SI. evaluated by psychiatry and he does not participate in care. He does have capacity to make decisions per psych. Inpatient psych was not effective in the past and given that he is refusing care now it was not thought to be of any benefit. Will offer extensive outpatient services- intake at Health Care for the Homeless-- patient refusing all offers and medications. denies SI on discharge. ACUTE/ACTIVE ISSUES: ==================== #MDD #Active SI Patient presentation was overall concerning for exacerbation of primary mood disorder. He endorsed significant depression as well as SI with plan to cut himself in the neck. Psychiatry evaluated in the emergency department and placed him on ___. He was admitted to medicine for ongoing psychiatric inpatient bed search. His home fluoxetine and doxepin were continued. He was started on standing ramelteon at bedtime to help with sleep. He was initially on Ativan PRN for agitation but it was stopped per recommendation by psych. Throughout admission patient did not engage in psychiatric evaluation nor the majority of his medical treatment. Eventually, recommendation was made by psychiatry to discharge him home, as he appeared to be at his baseline mental health state, prior psychiatric inpatient stay did not show significant benefit, and he was felt to have the capacity to refuse care. Social work provided information about partial programs for further treatment as an outpatient prior to discharge. Prior to discharge patient refused his psychiatric medications for multiple days. #Left anterior forearm injury Secondary to self-inflicted injury in ___ in setting of multiple self inflicted left wrist lacerations in the past. Underwent complex laceration repair on ___. Per hand surgery evaluation in ED, open injury several months post-op likely represents wound dehiscence for which patient will require hand surgery monitoring as an outpatient. Wet-to-dry dressings continued twice daily. Admitted on twice daily oxycodone for pain. He was felt to have no indication for continued opioid therapy for chronic pains during this admission as his wrist pain was minimal and his knee pain was more active as below. Was transitioned to acetaminophen 1000mg every 8 hours standing, naproxen 500mg every 12 hours as needed, lidocaine patch daily, BenGay cream as needed. He will follow-up in hand surgery clinic 2 weeks after discharge. #Knee Injury Secondary to injury two weeks prior while admitted to ___ ___ where x-ray was without any acute or chronic pathology. Evaluated by orthopedics in the ED and found to be neuro-vascularly intact with reassuring clinical exam. Recommended deferral of additional imaging at that time. Due to persistent severe pain he was re-evaluated by orthopedics while admitted to medicine who felt that his exam/symptoms were likely consistent with a meniscus tear but still did not warrant further imaging and that he pain was being appropriately treated with his regimen as above. They recommended that he follow up with them as an outpatient for further evaluation. CHRONIC/STABLE ISSUES: ====================== # Hypertension Continued home amlodipine, metop tartrate 100mg BID. Patient refused these medications for majority of hospitalization. # DM Provided 30U glargine at lunch time and Humalog ISS in addition to 1000mg metformin BID. patient refused these medications along with fingersticks for multiple days prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Doxepin HCl 100 mg PO HS 2. FLUoxetine 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 10 mg PO Q12H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 4. amLODIPine 10 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO BID 6. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. BD Ultra-Fine Mini Pen Needle (pen needle, diabetic) 31 gauge x ___ miscellaneous DAILY RX *pen needle, diabetic [Pen Needle] 32 gauge X ___ ASDIR ASDIR Disp #*30 Each Refills:*0 3. Glargine 22 Units Lunch Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic [FreeStyle Lite Strips] ASDIR once a day Disp #*30 Strip Refills:*0 RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) 30 units sc Before bed Disp #*25 Syringe Refills:*0 RX *blood-glucose meter [FreeStyle Lite Meter] ASDIR ASDIR Disp #*1 Kit Refills:*0 RX *lancets [FreeStyle Lancets] 28 gauge ASDIR once a day Disp #*30 Each Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QAM knee pain 5. Naproxen 500 mg PO Q12H:PRN Pain - Mild 6. Nicotine Polacrilex 4 mg PO Q2H:PRN craving RX *nicotine (polacrilex) 4 mg Every 2 hours Disp #*100 Gum Refills:*0 7. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Doxepin HCl 100 mg PO HS RX *doxepin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 9. FLUoxetine 20 mg PO DAILY RX *fluoxetine 20 mg 1 capsule(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. MetFORMIN (Glucophage) 500 mg PO BID RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Metoprolol Succinate XL 100 mg PO BID RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Major depressive disorder with suicidal ideation Type 2 diabetes Hypertension Left forearm injury Right knee injury 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 privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -You are admitted to the hospital so that you would be more comfortable with closer monitoring while awaiting a bed in a psychiatric hospital. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -We monitored you daily and did our best to treat your medical conditions as you allowed. –We attempted to optimize your regimen of pain medications to make you as comfortable as possible while you were with us. –Your blood sugars were very high when you were admitted and we restarted an insulin regimen to help treat this. -Your knee pain was persistent so we had orthopedics re-evaluate you. They felt like you may have a tear in your meniscus which should be followed up as an outpatient. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. - Please fill your prescriptions and take your medications as directed We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "F339", "R45851", "T8133XA", "S83206A", "I10", "E119", "Y69", "Z590", "I252", "Z87891", "R451" ]
Allergies: Ultram / Morphine / Tegretol / Thioridazine / Penicillins / nickel / Haldol / doxycycline / amitriptyline / nortriptyline / ketorolac / amoxicillin / azithromycin / Bactrim / erythromycin base / carbamazepine / Vicodin / Valium / codeine / tetracycline / clindamycin / Elavil / trazodone / tramadol / quetiapine Chief Complaint: Knee pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with history of HTN, DM, MDD w/ complex psychiatric history presented to the ED on [MASKED] for R knee pain. Patient stated he experienced injury to the knee while being restrained during recent psychiatric inpatient hospitalization at [MASKED] approximately 2 weeks ago. He describes that he was "chop-blocked" while being restrained during his last psychiatric stay. Injury represented force to external aspect of the knee with medial and internal rotation thereafter. Patient was discharged from [MASKED] on [MASKED]. Following discharge, he required wheel chair thereafter for approximately one week, however experienced gradual improvement to the point that he was able to ambulate with a cane. Patient is prescribed oxycodone for his pre-existing left arm injury and has been using that to medicate the RLE injury without relief. His ROS is otherwise notable for active suicidal ideation since discharge as well as continued pain in his existing left forearm injury. In the ED, initial vitals were: T: 97.1; HR: 74; BP: 121/73; RR: 16; PO2: 97% Exam was notable for: "R knee erythema, edema, tenderness to touch, pain with rom, [MASKED] strength L anterior wrist wound down to sub q fat, no purulent drainage, limited wrist rom and strength" Labs were notable for: CRP: 6.1; Hemoglobin: 13.3. U Tox positive for oxycodone (known home medication) Studies were notable for: Knee X-ray: "No fracture. Probable small suprapatellar effusion. Sclerotic regions in the distal right femur and proximal right tibia likely prior infarcts as seen previously." The patient was evaluated by orthopedics and hand service for knee and hand injuries respectively. Recommended activity as tolerated for knee and follow up in sports medicine clinic in [MASKED] weeks. Hand injury was most consistent with wound dehiscence that did not require inpatient intervention. Patient was additionally evaluated by psychiatry and deemed to meet [MASKED] criteria. Patient remained in emergency department from [MASKED] in the setting of an ongoing search for inpatient psychiatry care. During this time, he was continued on home doxepine 100/fluoxetine [MASKED] m and Ativan PO PRN. He did not require chemical sedation while in the emergency department. He was admitted to medicine pending psychiatric placement On arrival to the floor, endorses the above history. He is continuing to experience severe pain in both the arm and leg. He endorses ongoing SI however states "he does not wish to talk about it". Past Medical History: - Depression with prior SI/HI - HTN - DM - Seizure disorder, not on medications - GI bleed [MASKED] - Left flexor tendon repair ([MASKED] [MASKED] - Diabetes Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Notable for 1+ edema in bilateral lower extremities, R>L. Non-tender, non-erythematous. R knee with erythema and edema. Tender to palpation with limited flexion/extension of joint. Left anterior wrist bandaged but partial visualization notable for deep tissue injury with exposed subcutaneous tissue but no obvious purulence SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. [MASKED] strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== GENERAL: Alert, lying in bed. HEENT: Normocephalic, atraumatic. EOMI. LUNGS: No increased work of breathing on RA. Neuro: Alert, oriented, face symmetric. Pertinent Results: ADMISSION LABS: =============== [MASKED] 07:57PM BLOOD WBC-5.6 RBC-5.53 Hgb-13.3* Hct-43.9 MCV-79* MCH-24.1* MCHC-30.3* RDW-14.4 RDWSD-41.1 Plt [MASKED] [MASKED] 07:57PM BLOOD Neuts-53.0 [MASKED] Monos-5.0 Eos-1.3 Baso-0.5 Im [MASKED] AbsNeut-2.94 AbsLymp-2.21 AbsMono-0.28 AbsEos-0.07 AbsBaso-0.03 [MASKED] 07:57PM BLOOD Plt [MASKED] [MASKED] 07:57PM BLOOD CRP-6.1* [MASKED] 04:10PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 04:10PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [MASKED] 04:10PM URINE RBC-4* WBC-4 Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 04:10PM URINE Hours-RANDOM [MASKED] 04:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG DISCHARGE LABS: =============== None MICROBIOLOGY: ============= [MASKED] 4:10 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== [MASKED] Knee X-Ray: IMPRESSION: No fracture. Probable small suprapatellar effusion. Sclerotic regions in the distal right femur and proximal right tibia likely prior infarcts as seen previously. Brief Hospital Course: BRIEF HOSPITAL COURSE ===================== [MASKED] with history of HTN, DM, MDD w/ complex psychiatric history presented to the ED on [MASKED] for R knee pain i/s/o recent trauma deemed not to require acute intervention by orthopedics, however, admitted to medicine for active SI pending inpatient psychiatric placement. While awaiting placement patient's vitals and labs were monitored as patient allowed. He was noted to be hyperglycemic on admission and insulin was restarted. He was treated with 30 units of Lantus at lunchtime and a Humalog sliding scale in addition to home metformin. Psychiatry team followed while patient was admitted and assisted with management. Patient was having persistent knee pain from an injury sustained while at a prior psychiatric facility. This was evaluated by orthopedics in the emergency department and the recommendations were for weight bearing as tolerated and conservative pain management. There was no indication for further imaging from their perspective. Due to persistent, severe, knee pain orthopedics was called to re-evaluate while patient was admitted. They felt that while his exam was likely consistent with a meniscus tear that there was stil lno indication for further imaging and that his pain was being appropriately managed at that time. As hospitalization progressed patient began to engage in less and less of the medical care and psychiatric evaluation attempting to be provided. Eventually, after repeat psychiatric evaluation decision was made to discharge him to home as he appears to be at his baseline mental health state and despite being at a chronically elevated risk for self harm it was felt that inpatient psychiatric hospitalization was unlikely to be helpful. Prior to discharge social work saw patient and provided him with information regarding outpatient partial programs for further treatment. TRANSITIONAL ISSUES: ==================== – Ongoing titration of patient's diabetic regimen. Discharged on 30u Lantus QHS, Metformin 500mg BID. Would benefit from further education regarding importance of compliance with antihyperglycemic therapy. - Follow up appointments: PCP, [MASKED], Hand Surgery - Attempted to provide patient with refills for all new and continued chronic medications prior to discharge. He declined these medications but was provided prescriptions at discharge -SI: patient with intermittent ongoing SI. evaluated by psychiatry and he does not participate in care. He does have capacity to make decisions per psych. Inpatient psych was not effective in the past and given that he is refusing care now it was not thought to be of any benefit. Will offer extensive outpatient services- intake at Health Care for the Homeless-- patient refusing all offers and medications. denies SI on discharge. ACUTE/ACTIVE ISSUES: ==================== #MDD #Active SI Patient presentation was overall concerning for exacerbation of primary mood disorder. He endorsed significant depression as well as SI with plan to cut himself in the neck. Psychiatry evaluated in the emergency department and placed him on [MASKED]. He was admitted to medicine for ongoing psychiatric inpatient bed search. His home fluoxetine and doxepin were continued. He was started on standing ramelteon at bedtime to help with sleep. He was initially on Ativan PRN for agitation but it was stopped per recommendation by psych. Throughout admission patient did not engage in psychiatric evaluation nor the majority of his medical treatment. Eventually, recommendation was made by psychiatry to discharge him home, as he appeared to be at his baseline mental health state, prior psychiatric inpatient stay did not show significant benefit, and he was felt to have the capacity to refuse care. Social work provided information about partial programs for further treatment as an outpatient prior to discharge. Prior to discharge patient refused his psychiatric medications for multiple days. #Left anterior forearm injury Secondary to self-inflicted injury in [MASKED] in setting of multiple self inflicted left wrist lacerations in the past. Underwent complex laceration repair on [MASKED]. Per hand surgery evaluation in ED, open injury several months post-op likely represents wound dehiscence for which patient will require hand surgery monitoring as an outpatient. Wet-to-dry dressings continued twice daily. Admitted on twice daily oxycodone for pain. He was felt to have no indication for continued opioid therapy for chronic pains during this admission as his wrist pain was minimal and his knee pain was more active as below. Was transitioned to acetaminophen 1000mg every 8 hours standing, naproxen 500mg every 12 hours as needed, lidocaine patch daily, BenGay cream as needed. He will follow-up in hand surgery clinic 2 weeks after discharge. #Knee Injury Secondary to injury two weeks prior while admitted to [MASKED] [MASKED] where x-ray was without any acute or chronic pathology. Evaluated by orthopedics in the ED and found to be neuro-vascularly intact with reassuring clinical exam. Recommended deferral of additional imaging at that time. Due to persistent severe pain he was re-evaluated by orthopedics while admitted to medicine who felt that his exam/symptoms were likely consistent with a meniscus tear but still did not warrant further imaging and that he pain was being appropriately treated with his regimen as above. They recommended that he follow up with them as an outpatient for further evaluation. CHRONIC/STABLE ISSUES: ====================== # Hypertension Continued home amlodipine, metop tartrate 100mg BID. Patient refused these medications for majority of hospitalization. # DM Provided 30U glargine at lunch time and Humalog ISS in addition to 1000mg metformin BID. patient refused these medications along with fingersticks for multiple days prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Doxepin HCl 100 mg PO HS 2. FLUoxetine 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 10 mg PO Q12H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 4. amLODIPine 10 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO BID 6. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. BD Ultra-Fine Mini Pen Needle (pen needle, diabetic) 31 gauge x [MASKED] miscellaneous DAILY RX *pen needle, diabetic [Pen Needle] 32 gauge X [MASKED] ASDIR ASDIR Disp #*30 Each Refills:*0 3. Glargine 22 Units Lunch Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic [FreeStyle Lite Strips] ASDIR once a day Disp #*30 Strip Refills:*0 RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) 30 units sc Before bed Disp #*25 Syringe Refills:*0 RX *blood-glucose meter [FreeStyle Lite Meter] ASDIR ASDIR Disp #*1 Kit Refills:*0 RX *lancets [FreeStyle Lancets] 28 gauge ASDIR once a day Disp #*30 Each Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QAM knee pain 5. Naproxen 500 mg PO Q12H:PRN Pain - Mild 6. Nicotine Polacrilex 4 mg PO Q2H:PRN craving RX *nicotine (polacrilex) 4 mg Every 2 hours Disp #*100 Gum Refills:*0 7. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Doxepin HCl 100 mg PO HS RX *doxepin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 9. FLUoxetine 20 mg PO DAILY RX *fluoxetine 20 mg 1 capsule(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. MetFORMIN (Glucophage) 500 mg PO BID RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Metoprolol Succinate XL 100 mg PO BID RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Major depressive disorder with suicidal ideation Type 2 diabetes Hypertension Left forearm injury Right knee injury 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 privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -You are admitted to the hospital so that you would be more comfortable with closer monitoring while awaiting a bed in a psychiatric hospital. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -We monitored you daily and did our best to treat your medical conditions as you allowed. –We attempted to optimize your regimen of pain medications to make you as comfortable as possible while you were with us. –Your blood sugars were very high when you were admitted and we restarted an insulin regimen to help treat this. -Your knee pain was persistent so we had orthopedics re-evaluate you. They felt like you may have a tear in your meniscus which should be followed up as an outpatient. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. - Please fill your prescriptions and take your medications as directed We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I10", "E119", "I252", "Z87891" ]
[ "F339: Major depressive disorder, recurrent, unspecified", "R45851: Suicidal ideations", "T8133XA: Disruption of traumatic injury wound repair, initial encounter", "S83206A: Unspecified tear of unspecified meniscus, current injury, right knee, initial encounter", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Y69: Unspecified misadventure during surgical and medical care", "Z590: Homelessness", "I252: Old myocardial infarction", "Z87891: Personal history of nicotine dependence", "R451: Restlessness and agitation" ]
10,061,677
27,512,307
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ultram / Morphine / Tegretol / Thioridazine / Penicillins / nickel / Haldol / doxycycline / amitriptyline / nortriptyline / ketorolac / amoxicillin / azithromycin / Bactrim / erythromycin base / carbamazepine / Vicodin / Valium / codeine / tetracycline / clindamycin / Elavil / trazodone / tramadol / quetiapine Attending: ___. Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with history of recent self-inflicted laceration to left wrist (___), currently inpatient at ___ for SI, who presents with worsening wound odor and drainage. Patient was recently re-evaluated in ED by hand surgery with wound washed on ___. Wound has been getting dressed daily. About a week ago, he developed swelling of the arm. Laceration sit split open and he noted bad odor and discharge. Has started developing fevers and chills. Pain is worse at laceration site and medial aspect of forearm In the ED, initial vitals were 95.1 113 132/78 22 96% RA glc 434. On exam, there was right wrist laceration open with tendon exposed, some purulence on margin or wound. Right hand and forearm were swollen. There was significant tenderness to light palpation, no surrounding erythema. He was able to move right fingers though limited by pain. Distal sensation was intact. Radial pulse was noted on doppler. Labs showed WBC 6.1K, lactate 2.3. Blood and urine cultures were sent. He received acetaminophen 1000 mg x 1, oxycodone 10 mg x 1, hydromorphone 1 mg IV x 3, hydromorphone 4 mg PO x 2, IV vancomycin 1500 mg x 2, cefepime 2 grams IV x 1, nicotine patch, 1 liter LR, doxepin 100 mg x 1, spironolactone 25 mg PO x 1, amoxicillin-clavulanic acid ___ mg x 1, 6 units insulin. Left forearm X-ray showed No significant change. Possible ulceration over the ulnar volar aspect of the wrist, but no soft tissue emphysema. Lactate improved to 0.5. He has one small IV in place. Hand was consulted recommended local wound care with BID wet to dry dressings and follow up with Hand Surgery. Patient is on ___. Currently, the patient reports ___ pain in his left hand, currently wrapped. He reports intermittent fevers. Review of systems: 10 pt ROS negative other than noted Past Medical History: - Depression with prior SI/HI - GSW ___ - Seizure disorder, not on medications - GI bleed ___ - Left flexor tendon repair (___ ___ - Diabetes Social History: ___ Family History: Refuses to answer this Physical Exam: ADMISSION EXAM: Vitals: ___ ___ Temp: 99.9 PO BP: 105/84 HR: 121 RR: 18 O2 sat: 93% O2 delivery: RA ___ ___ Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. Obese. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: 2+ lower leg edema bilaterally to knees. Left hand wrapped, in ED: Right wrist laceration open with tendon exposed, some purulence on margin or wound. Right hand and forearm swollen. Significant tenderness to light palpation. No surrounding erythema. Able to move right fingers though limited by pain. Distal sensation intact. Radial pulse on doppler DERM: No active rash. Neuro: moving all four extremities purposefully, non-focal. PSYCH: Appropriate and calm. Flat affect DISCHARGE EXAM: VS: see EFlowsheets General: NAD, resting comfortably Cardiac: RRR Lungs: CTAB Extremities: L hand wound open with healing granulation tissue, no erythema or purulence Neuro: moving all extremities Psych: overall pleasant this morning with appropriate affect Pertinent Results: Admission Labs: =============== ___ 02:55PM BLOOD WBC-6.1 RBC-4.99 Hgb-13.3* Hct-41.8 MCV-84 MCH-26.7 MCHC-31.8* RDW-13.3 RDWSD-40.5 Plt ___ ___ 02:55PM BLOOD Neuts-61.1 ___ Monos-6.5 Eos-1.6 Baso-0.5 Im ___ AbsNeut-3.75 AbsLymp-1.83 AbsMono-0.40 AbsEos-0.10 AbsBaso-0.03 ___ 02:55PM BLOOD ___ PTT-27.9 ___ ___ 02:55PM BLOOD Glucose-359* UreaN-8 Creat-0.7 Na-135 K-4.9 Cl-94* HCO3-26 AnGap-15 ___ 03:05PM BLOOD Lactate-2.3* ___ 08:20AM BLOOD Lactate-0.5 Imaging: ======== Left forearm X-ray on admission: No significant change. Possible ulceration over the ulnar volar aspect of the wrist, but no soft tissue emphysema. Discharge Labs: =============== ___ 06:20AM BLOOD WBC-4.5 RBC-4.75 Hgb-12.3* Hct-39.7* MCV-84 MCH-25.9* MCHC-31.0* RDW-13.0 RDWSD-39.4 Plt ___ ___ 06:20AM BLOOD Glucose-364* UreaN-8 Creat-0.6 Na-137 K-4.7 Cl-98 HCO3-26 AnGap-13 ___ 06:20AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.___ year old male with history of recent self-inflicted laceration to left wrist (___), currently inpatient at ___ ___ for suicidal ideation, who presented with worsening wound odor and drainage. # Left hand/forearm wound # Fever # Tachycardia # Hand pain: multiple prior surgeries for self-inflicted left wrist injuries, most recently ___ for left wrist complex repair, presenting with wound dehiscence. On exam, he had wet granulation tissue with no active drainage or purulence. Flexion contractures and significant scarring were consistent with prior injuries. Patient has had multiple trials of different options to manage his wounds which have failed due to self discontinuing these trials, at this time pursuing non-operative management. He was febrile to 100.8 on admission. Due to concern for wound infection he was started on empiric vancomycin. He was seen by both hand surgery and the wound care nurse, who felt that the wound was healing well with no signs of active infection. Antibiotics were stopped and he had no further fevers. In terms of alternative causes of fever, CXR was negative for acute abnormality. He had no other localizing symptoms. Blood cultures were negative at time of discharge. # Depression # Suicidal attempt/ideation: currently on ___. Psychiatry made no changes to his current medications at ___, which included fluoxetine, doxepin and prazosin. He will return to ___ after discharge. # ? Hypertension: patient states that he does not take any medications, but is reported at ___ as taking amlodipine, spironolactone and metoprolol. He refused his anti-hypertensive medications apart from taking Metoprolol occasionally. Blood pressures were mildly elevated in the 150 systolic range - likely would benefit from restarting amlodipine if he is agreeable. # Diabetes, uncontrolled with hyperglycemia: reportedly receives sliding scale insulin at home, and was started on metformin in the past, which he states he did not take. A1C was 10.1, and patient was consistently hyperglycemic. ___ was consulted and he was started on lantus 25 units and an insulin sliding scale > 30 minutes spent on discharge coordination and planning Transitional Issues: ==================== - needs daily wet to dry dressing changes - discharged on oxycodone 10mg QID, he will hopefully not require more than 5 additional days of narcotic therapy. If persistent pain after five days, can call ___ hand surgery clinic at ___ to possibly arrange earlier follow up (currently scheduled for ___ - spironolactone and clonidine stopped at discharged - started on metformin and insulin (lantus 25 units, insulin sliding scale) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. FLUoxetine 20 mg PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. amLODIPine 10 mg PO DAILY 4. CloNIDine 0.1 mg PO Q6H 5. Doxepin HCl 100 mg PO HS 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 9. Prazosin 3 mg PO QHS 10. Spironolactone 25 mg PO DAILY 11. Nicotine Polacrilex 4 mg PO Q2H:PRN nicotine cravings 12. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 13. Bacitracin Ointment 1 Appl TP BID 14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line 15. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN indigestion Discharge Medications: 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Glargine 25 Units Lunch Insulin SC Sliding Scale using HUM Insulin 4. OxyCODONE (Immediate Release) 10 mg PO QID Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 10 mg 1 tablet(s) by mouth four times a day Disp #*20 Tablet Refills:*0 5. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN indigestion 6. amLODIPine 10 mg PO DAILY 7. Doxepin HCl 100 mg PO HS 8. FLUoxetine 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line 11. Nicotine Polacrilex 4 mg PO Q2H:PRN nicotine cravings 12. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Prazosin 3 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: hand laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to the hospital with left hand and forearm pain. You were seen by the hand surgeons who did not find any signs that the wound was infected. It will be important to follow up with the surgeons in clinic and to change the wound dressing once a day. It was a pleasure taking care of you, and we are happy that you're feeling better! Followup Instructions: ___
[ "T8133XA", "R45851", "Z6843", "E872", "R509", "F329", "I10", "E669", "Z720", "Z590", "I252", "Z8673", "F4310", "Z9119", "E1165", "Z794" ]
Allergies: Ultram / Morphine / Tegretol / Thioridazine / Penicillins / nickel / Haldol / doxycycline / amitriptyline / nortriptyline / ketorolac / amoxicillin / azithromycin / Bactrim / erythromycin base / carbamazepine / Vicodin / Valium / codeine / tetracycline / clindamycin / Elavil / trazodone / tramadol / quetiapine Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] year old male with history of recent self-inflicted laceration to left wrist ([MASKED]), currently inpatient at [MASKED] for SI, who presents with worsening wound odor and drainage. Patient was recently re-evaluated in ED by hand surgery with wound washed on [MASKED]. Wound has been getting dressed daily. About a week ago, he developed swelling of the arm. Laceration sit split open and he noted bad odor and discharge. Has started developing fevers and chills. Pain is worse at laceration site and medial aspect of forearm In the ED, initial vitals were 95.1 113 132/78 22 96% RA glc 434. On exam, there was right wrist laceration open with tendon exposed, some purulence on margin or wound. Right hand and forearm were swollen. There was significant tenderness to light palpation, no surrounding erythema. He was able to move right fingers though limited by pain. Distal sensation was intact. Radial pulse was noted on doppler. Labs showed WBC 6.1K, lactate 2.3. Blood and urine cultures were sent. He received acetaminophen 1000 mg x 1, oxycodone 10 mg x 1, hydromorphone 1 mg IV x 3, hydromorphone 4 mg PO x 2, IV vancomycin 1500 mg x 2, cefepime 2 grams IV x 1, nicotine patch, 1 liter LR, doxepin 100 mg x 1, spironolactone 25 mg PO x 1, amoxicillin-clavulanic acid [MASKED] mg x 1, 6 units insulin. Left forearm X-ray showed No significant change. Possible ulceration over the ulnar volar aspect of the wrist, but no soft tissue emphysema. Lactate improved to 0.5. He has one small IV in place. Hand was consulted recommended local wound care with BID wet to dry dressings and follow up with Hand Surgery. Patient is on [MASKED]. Currently, the patient reports [MASKED] pain in his left hand, currently wrapped. He reports intermittent fevers. Review of systems: 10 pt ROS negative other than noted Past Medical History: - Depression with prior SI/HI - GSW [MASKED] - Seizure disorder, not on medications - GI bleed [MASKED] - Left flexor tendon repair ([MASKED] [MASKED] - Diabetes Social History: [MASKED] Family History: Refuses to answer this Physical Exam: ADMISSION EXAM: Vitals: [MASKED] [MASKED] Temp: 99.9 PO BP: 105/84 HR: 121 RR: 18 O2 sat: 93% O2 delivery: RA [MASKED] [MASKED] Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. Obese. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: 2+ lower leg edema bilaterally to knees. Left hand wrapped, in ED: Right wrist laceration open with tendon exposed, some purulence on margin or wound. Right hand and forearm swollen. Significant tenderness to light palpation. No surrounding erythema. Able to move right fingers though limited by pain. Distal sensation intact. Radial pulse on doppler DERM: No active rash. Neuro: moving all four extremities purposefully, non-focal. PSYCH: Appropriate and calm. Flat affect DISCHARGE EXAM: VS: see EFlowsheets General: NAD, resting comfortably Cardiac: RRR Lungs: CTAB Extremities: L hand wound open with healing granulation tissue, no erythema or purulence Neuro: moving all extremities Psych: overall pleasant this morning with appropriate affect Pertinent Results: Admission Labs: =============== [MASKED] 02:55PM BLOOD WBC-6.1 RBC-4.99 Hgb-13.3* Hct-41.8 MCV-84 MCH-26.7 MCHC-31.8* RDW-13.3 RDWSD-40.5 Plt [MASKED] [MASKED] 02:55PM BLOOD Neuts-61.1 [MASKED] Monos-6.5 Eos-1.6 Baso-0.5 Im [MASKED] AbsNeut-3.75 AbsLymp-1.83 AbsMono-0.40 AbsEos-0.10 AbsBaso-0.03 [MASKED] 02:55PM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 02:55PM BLOOD Glucose-359* UreaN-8 Creat-0.7 Na-135 K-4.9 Cl-94* HCO3-26 AnGap-15 [MASKED] 03:05PM BLOOD Lactate-2.3* [MASKED] 08:20AM BLOOD Lactate-0.5 Imaging: ======== Left forearm X-ray on admission: No significant change. Possible ulceration over the ulnar volar aspect of the wrist, but no soft tissue emphysema. Discharge Labs: =============== [MASKED] 06:20AM BLOOD WBC-4.5 RBC-4.75 Hgb-12.3* Hct-39.7* MCV-84 MCH-25.9* MCHC-31.0* RDW-13.0 RDWSD-39.4 Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-364* UreaN-8 Creat-0.6 Na-137 K-4.7 Cl-98 HCO3-26 AnGap-13 [MASKED] 06:20AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.[MASKED] year old male with history of recent self-inflicted laceration to left wrist ([MASKED]), currently inpatient at [MASKED] [MASKED] for suicidal ideation, who presented with worsening wound odor and drainage. # Left hand/forearm wound # Fever # Tachycardia # Hand pain: multiple prior surgeries for self-inflicted left wrist injuries, most recently [MASKED] for left wrist complex repair, presenting with wound dehiscence. On exam, he had wet granulation tissue with no active drainage or purulence. Flexion contractures and significant scarring were consistent with prior injuries. Patient has had multiple trials of different options to manage his wounds which have failed due to self discontinuing these trials, at this time pursuing non-operative management. He was febrile to 100.8 on admission. Due to concern for wound infection he was started on empiric vancomycin. He was seen by both hand surgery and the wound care nurse, who felt that the wound was healing well with no signs of active infection. Antibiotics were stopped and he had no further fevers. In terms of alternative causes of fever, CXR was negative for acute abnormality. He had no other localizing symptoms. Blood cultures were negative at time of discharge. # Depression # Suicidal attempt/ideation: currently on [MASKED]. Psychiatry made no changes to his current medications at [MASKED], which included fluoxetine, doxepin and prazosin. He will return to [MASKED] after discharge. # ? Hypertension: patient states that he does not take any medications, but is reported at [MASKED] as taking amlodipine, spironolactone and metoprolol. He refused his anti-hypertensive medications apart from taking Metoprolol occasionally. Blood pressures were mildly elevated in the 150 systolic range - likely would benefit from restarting amlodipine if he is agreeable. # Diabetes, uncontrolled with hyperglycemia: reportedly receives sliding scale insulin at home, and was started on metformin in the past, which he states he did not take. A1C was 10.1, and patient was consistently hyperglycemic. [MASKED] was consulted and he was started on lantus 25 units and an insulin sliding scale > 30 minutes spent on discharge coordination and planning Transitional Issues: ==================== - needs daily wet to dry dressing changes - discharged on oxycodone 10mg QID, he will hopefully not require more than 5 additional days of narcotic therapy. If persistent pain after five days, can call [MASKED] hand surgery clinic at [MASKED] to possibly arrange earlier follow up (currently scheduled for [MASKED] - spironolactone and clonidine stopped at discharged - started on metformin and insulin (lantus 25 units, insulin sliding scale) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. FLUoxetine 20 mg PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. amLODIPine 10 mg PO DAILY 4. CloNIDine 0.1 mg PO Q6H 5. Doxepin HCl 100 mg PO HS 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 9. Prazosin 3 mg PO QHS 10. Spironolactone 25 mg PO DAILY 11. Nicotine Polacrilex 4 mg PO Q2H:PRN nicotine cravings 12. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 13. Bacitracin Ointment 1 Appl TP BID 14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line 15. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN indigestion Discharge Medications: 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Glargine 25 Units Lunch Insulin SC Sliding Scale using HUM Insulin 4. OxyCODONE (Immediate Release) 10 mg PO QID Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 10 mg 1 tablet(s) by mouth four times a day Disp #*20 Tablet Refills:*0 5. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN indigestion 6. amLODIPine 10 mg PO DAILY 7. Doxepin HCl 100 mg PO HS 8. FLUoxetine 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line 11. Nicotine Polacrilex 4 mg PO Q2H:PRN nicotine cravings 12. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Prazosin 3 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: hand laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to the hospital with left hand and forearm pain. You were seen by the hand surgeons who did not find any signs that the wound was infected. It will be important to follow up with the surgeons in clinic and to change the wound dressing once a day. It was a pleasure taking care of you, and we are happy that you're feeling better! Followup Instructions: [MASKED]
[]
[ "E872", "F329", "I10", "E669", "I252", "Z8673", "E1165", "Z794" ]
[ "T8133XA: Disruption of traumatic injury wound repair, initial encounter", "R45851: Suicidal ideations", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "E872: Acidosis", "R509: Fever, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "Z720: Tobacco use", "Z590: Homelessness", "I252: Old myocardial infarction", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F4310: Post-traumatic stress disorder, unspecified", "Z9119: Patient's noncompliance with other medical treatment and regimen", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin" ]
10,061,731
25,629,152
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cough, vomiting, fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history of lymphoplasmacytic lymphoma and IgG kappa MGUS c/b kidney injury now C5D16 (treated yesterday) BDR (bendamustine, dexamethasone, rituxan) who presents with fever. He had URI symptoms one week ago with a fever. He had viral panel and CXR that were negative. He had been getting better over the last several days. However, he had chemotherapy the day prior to admission. Following this he started to feel sick again, similar to his prior symptoms. He reports cough with yellow sputum production, nasal congestion, and headache. He notes decreased PO intake over the last few days. He had a fever the day of admission to 100.8. He also had nausea with three episodes of ___ vomiting. On arrival to the ED, initial vitals were 99.9 108 119/79 18 94% RA. Labs were notable for WBC 26.7 (PMNs 93.7%, lymphs 0.6%), H/H 12.4/38.7, Plt 172, Na 135, BUN/Cr ___ -> ___, ALT 133, AST 128, ALP 174, Tbili 1.1, lactate 3.1 -> 2.1, UA negative, and influenza PCR negative. CXR was negative for pneumonia. Patient was given pantoprazole 40mg PO, Zofran 4mg IV, azithromycin 500mg PO, Tylenol 1g PO, and 2L NS. Vitals prior to transfer were 99.2 84 101/53 16 96% RA. On arrival to the floor, he reports that he is feeling much better. He has more energy. He believes that he was dehydrated. He denies headache, neck stiffness, sore throat, shortness of breath, chest pain, abdominal pain, diarrhea, hematuria, and dysuria. REVIEW OF SYSTEMS: A complete ___ review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: This patient was seen by PCP with an elevated creatinine in ___ and was referred to Dr. ___ from ___ here at ___. The patient had a new diagnosis of kidney disease with an elevated creatinine from ___ in ___. Initial Ptn/Creat ratio was as high as 2.4. The patient also had a renal ultrasound done on ___ that showed that both kidneys appeared normal. UPEP and urine IFE showed MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN ___ KAPPA DETECTED REPRESENTED ROUGHLY 15% OF URINARY PROTEIN BASED ON THIS SAMPLE'S PROTEIN/CREATININE RATIO AND ASSUMING DAILY CREATININE EXCRETION OF 1000 MG THIS PATIENT'S ___ EXCRETION wAS estimated at 15% * 1.6 * 1000 = 240 MG/DAY. Based on this pt was referred to us to r.o MM. We did not have prior lab data to compare. Serum IFE demonstrated IgG Kappa M ptn with 0.7gm/dl of protein. He had a negative skeletal survey on ___. His free kappa lambda ratio was 12.82 with a ___ microglobulin of 4.49. The patient was not anemic, did not show any evidence of hypercalcemia. - BM biopsy performed on ___ demonstrated hyperellular marrow with kappa restricted lymphoplasmacytic lymphoma with pos MYD88 mutation detection. No plasma cell dyscrasia seen. - ___: CT scans of the chest/abd/pelvis did not demonstrate and adenopathy. Mild splenomegaly 13.2 cm was noted. Renal biopsy was recommended by us to the nephrology team. - ___: Underwent renal biopsy that demonstrated acute on chronic tubular injury, likely from the patient's known ___ proteinuria. Case was reviewed by hemepath who saw evidence of lymphoplasmacytic lymphoma in the biopsy specimen but this was felt to be a fragment of an inadvertently sampled LN rather than actual renal involvement with lymphoma. Case discussed with Dr ___ recommended treatment of the lymphoma that was causing the ptnuria from acute on chronic tubular injury. This was reflective of the nephrology team consensus. - Given absence of symptomatic systemic lymphoma, it was decide to start treatment with single agent Rituximab. - ___ and ___ rcd 4 weekly doses of Rituxan. - ___: PET demonstrated no e.o lymphoma or lytic lesions. - ___: Evaluated by Nephrology and felt to have improvement in ptnuria which was lower at 1.3 compared to ___ previously. Additionally the percent/amount of ___ proteinuria was less than previous values, but not completely negative. However continued to have glycosuria, hypouricemia, and hypophosphatemia indicating continued proximal tubule wasting. With so little ___ protein in the urine, it was unclear if there is ongoing injury with this small amount. - ___: Case discussed again and felt that we should add Velcade and Dex to the regimen. - ___: Started on BDR regimen (Velcade/Dex and Rituximab) for treatment of ongoing light chain proximal tubulopathy. Ptn/Creat ratio was 1.6 gm/day before starting Velcade. - Rcd Velcade at 1.3 mg/m2 IV on days 1,___ and ___. Tolerated cycle 1 very well with no complications. - ___: Ptn/creat ration decreased to 1gm/day after cycle 1 of Velcade. Rcd cycle 2 of BDR in which rcd Velcade given at 1.6 mg/m2 and Dex ___ mg along with Rituxan on days 1,___ and ___. LFT's were elevated during course of Tx. Lipitor held. - Course complicated by brief episodes of dizziness and diarrhea after Velcade doses for a few hours that resolved by itself. - ___: Ptn/Creat ratio improved to 0.7 gm/day. Given episodes of hypotension/dizziness post Velcade administration and concern for autonomic neuropathy sec to Velcade , dose of Velcade was reduced to 1.3 mg/m2 and cycle 3 administered. Tolerated well with reduction in dose. - ___: Ptn/Creat ratio improved to 0.7 gm/day. Given neuropathy,dose of Velcade was reduced further to 0.7 mg/m2 and cycle 4 administered. Tolerated it well with reduction in dose. PAST MEDICAL HISTORY: 1. Small colonic benign adenomatous polyp for which he will have a repeat colonoscopy in ___ years. 2. Obstructive sleep apnea for which he wears a CPAP for the last ___ years. 3. Anxiety, on Celexa. 4. Bilateral hip bursitis. 5. Rare ocular migraines. 6. Hyperlipidemia. 7. Status post appendectomy in ___. 8. Status post cholecystectomy about five to ___ years ago. 9. New diagnosis of hypertension for which he is on amlodipine. Social History: ___ Family History: Not available as the patient is adopted. Physical Exam: ADMISSION PHYSICAL EXAM ================= VS: Temp 99.2, BP 110/64, HR 71, RR 18, O2 sat 96% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: Alert, oriented, good attention and linear thought, CN ___ intact. Strength full throughout. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM ================== VS: 99.2 Tmax 101.8 at midnight ___ BP 118/76 HR 74 RR 16 97%RA GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Lungs CTA bilaterally. No wheezing, rales or rhonchi. ABD: NABS. Abd soft, nontender, nondistended, no hepatomegaly, no splenomegaly. No rebound or guarding. EXT: Warm, well perfused,2+ DP pulses NEURO: Alert, oriented, good attention and linear thought, CN ___ intact. Strength full throughout. SKIN: No significant rashes. Pertinent Results: LABS ON ADMISSION ============= ___ 10:20AM BLOOD ___ ___ Plt ___ ___ 10:20AM BLOOD ___ ___ Im ___ ___ ___ 10:20AM BLOOD Plt ___ ___ 10:20AM BLOOD ___ ___ ___ 10:20AM BLOOD ___ ___ 10:20AM BLOOD ___ ___ 10:20AM BLOOD ___ B ___ ___ NOTABLE LABS ========= ___ 10:20AM BLOOD ___ ___ Plt ___ ___ 05:21PM BLOOD ___ ___ Plt ___ ___ 06:40AM BLOOD ___ ___ Plt ___ ___ 10:20AM BLOOD ___ ___ Im ___ ___ ___ 05:21PM BLOOD ___ ___ Im ___ ___ ___ 10:20AM BLOOD ___ ___ 05:21PM BLOOD ___ ___ ___ 07:03PM BLOOD ___ ___ 06:40AM BLOOD ___ ___ 06:40AM BLOOD ___ ___ 10:20AM BLOOD ___ B ___ ___ ___ 05:32PM BLOOD ___ ___ 08:16PM BLOOD ___ ___ 07:11AM BLOOD ___ LABS ON DISCHARGE ============= ___ 06:40AM BLOOD ___ ___ Plt ___ ___ 05:21PM BLOOD ___ ___ Im ___ ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD ___ ___ ___ 06:40AM BLOOD ___ ___ 06:40AM BLOOD ___ ___ 05:21PM BLOOD ___ ___ 06:40AM BLOOD ___ ___:11AM BLOOD ___ IMAGING ====== CXR PA & LATERAL (___) FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. Hilar contours are stable. IMPRESSION: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICROBIOLOGY ========== GENERAL URINE INFORMATION Urine ColorYellow W Urine AppearanceClear W Specific Gravity1.0281.001 - 1.035W DIPSTICK URINALYSIS BloodSM W NitriteNEG W Protein100 mg/dLW Glucose300 mg/dLW KetoneNEG mg/dLW BilirubinNEG mg/dLW UrobilinogenNEG0.2 - 1mg/dLW pH6.05 - 8unitsW LeukocytesNEG W MICROSCOPIC URINE EXAMINATION RBC10 - 2#/hpfW WBC10 - 5#/hpfW BacteriaNONE W YeastNONE W Epithelial Cells<1 #/hpfW URINE CASTS Hyaline Casts2*0 - 0#/lpfW OTHER URINE FINDINGS Urine MucousRARE W ___ 7:03 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:21 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 7:44 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 5:45 pm Rapid Respiratory Viral Screen & Culture 3. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. __________________________________________________________ ___ 12:00 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Brief Hospital Course: Mr. ___ is a ___ male with history of lymphoplasmacytic lymphoma and IgG kappa MGUS c/b kidney injury now C5D18 (treated day prior to admission) BDR (bortezomib, dexamethasone, rituxan) who presented with fever and leukocytosis. During the course of his hospital stay, the following issues were addressed: # Fever/Cough: Patient with fever and URI symptoms most likely consistent with viral infection. Influenza and Respiratory viral screen were negative. CXR with no active infiltrate. Lactate was initially elevated at 3.1 but downtrended overnight with IVF to 1.6 on discharge. Patient was discharged with a ___ course of azithromycin for empiric coverage of possible bacterial superinfection. # Transaminitis: Initial ALT 133 and AST 128, ALP 174 (but specimen hemolyzed). Immediate ___ labs with ALT of 103, AST 68, andALP 151. Overnight there was a slight improvement with ALT of 97, AST 56 and ALP 149 coinciding with IV fluid administration, Patient has had intermittent transaminitis in past and has never had bx per OMR. ALT and AST down from admission with fluid administration. # Leukocytosis: WBC 26.7 on admission. Secondary to infection as above vs. steroids received yesterday with chemotherapy. Downtrended to 12.9 on discharge. # ___ on CKD: Patient presented with Cr 1.8 up from baseline 1.5. Improved after IVF to baseline. Creatinine on discharge was 1.6. # Hypertension. Held lisinopril in setting of ___. Normotensive during hospital stay. # Anxiety. Continued citalopram. Continued Ativan prn. TRANSITIONAL ISSUES ============== - Azithromycin 5 day course (Start ___ | End ___ - Holding lisinopril due to ___ (Cr at discharge at baseline of 1.6). Will need to be restarted with primary oncologist/PCP - ___ viral culture pending - If patient spikes fevers during next cycle of BDR, then we know this is more likely a reaction to chemotherapy. - Transaminitis: Patient has had intermittent transaminitis in past; has never had bx. ALT and AST down from admission with fluid administration. Consider further ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO BID 2. Lisinopril 2.5 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Dapsone 100 mg PO DAILY 5. LORazepam 0.5 mg PO QHS:PRN insomnia 6. Pantoprazole 40 mg PO Q24H 7. Prochlorperazine 10 mg PO Q8H:PRN nausea/vomiting 8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 9. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Days RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*3 Tablet Refills:*0 2. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 3. GuaiFENesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6 Refills:*0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Acyclovir 400 mg PO BID 6. Citalopram 20 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. LORazepam 0.5 mg PO QHS:PRN insomnia 10. Pantoprazole 40 mg PO Q24H 11. Prochlorperazine 10 mg PO Q8H:PRN nausea/vomiting 12. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until you discuss with your primary oncologist Discharge Disposition: Home Discharge Diagnosis: Primary ===== Lymphoplasmacytic lymphoma with IgG kappa MGUS URI Acute on Chronic Kidney Disease Secondary ======= Hypertension Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure caring for you here at ___. You presented with a fever of 100.8 , cough and 3 days of vomiting. You did well in the hospital and were discharged with a ___ course of antibiotics to cover for a possible bacterial infection on top of what is likely a viral respiratory infection. Please take azithromycin for 3 more days and do not take your lisinopril until discussing with Dr. ___. If you experience any of the danger signs below, please contact your oncologist or come to the emergency department. Best Wishes, Your ___ Care Team Followup Instructions: ___
[ "J069", "N179", "C8309", "D472", "I129", "N189", "G4733", "R740", "F419", "D72828", "R803" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Cough, vomiting, fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with history of lymphoplasmacytic lymphoma and IgG kappa MGUS c/b kidney injury now C5D16 (treated yesterday) BDR (bendamustine, dexamethasone, rituxan) who presents with fever. He had URI symptoms one week ago with a fever. He had viral panel and CXR that were negative. He had been getting better over the last several days. However, he had chemotherapy the day prior to admission. Following this he started to feel sick again, similar to his prior symptoms. He reports cough with yellow sputum production, nasal congestion, and headache. He notes decreased PO intake over the last few days. He had a fever the day of admission to 100.8. He also had nausea with three episodes of [MASKED] vomiting. On arrival to the ED, initial vitals were 99.9 108 119/79 18 94% RA. Labs were notable for WBC 26.7 (PMNs 93.7%, lymphs 0.6%), H/H 12.4/38.7, Plt 172, Na 135, BUN/Cr [MASKED] -> [MASKED], ALT 133, AST 128, ALP 174, Tbili 1.1, lactate 3.1 -> 2.1, UA negative, and influenza PCR negative. CXR was negative for pneumonia. Patient was given pantoprazole 40mg PO, Zofran 4mg IV, azithromycin 500mg PO, Tylenol 1g PO, and 2L NS. Vitals prior to transfer were 99.2 84 101/53 16 96% RA. On arrival to the floor, he reports that he is feeling much better. He has more energy. He believes that he was dehydrated. He denies headache, neck stiffness, sore throat, shortness of breath, chest pain, abdominal pain, diarrhea, hematuria, and dysuria. REVIEW OF SYSTEMS: A complete [MASKED] review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: This patient was seen by PCP with an elevated creatinine in [MASKED] and was referred to Dr. [MASKED] from [MASKED] here at [MASKED]. The patient had a new diagnosis of kidney disease with an elevated creatinine from [MASKED] in [MASKED]. Initial Ptn/Creat ratio was as high as 2.4. The patient also had a renal ultrasound done on [MASKED] that showed that both kidneys appeared normal. UPEP and urine IFE showed MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN [MASKED] KAPPA DETECTED REPRESENTED ROUGHLY 15% OF URINARY PROTEIN BASED ON THIS SAMPLE'S PROTEIN/CREATININE RATIO AND ASSUMING DAILY CREATININE EXCRETION OF 1000 MG THIS PATIENT'S [MASKED] EXCRETION wAS estimated at 15% * 1.6 * 1000 = 240 MG/DAY. Based on this pt was referred to us to r.o MM. We did not have prior lab data to compare. Serum IFE demonstrated IgG Kappa M ptn with 0.7gm/dl of protein. He had a negative skeletal survey on [MASKED]. His free kappa lambda ratio was 12.82 with a [MASKED] microglobulin of 4.49. The patient was not anemic, did not show any evidence of hypercalcemia. - BM biopsy performed on [MASKED] demonstrated hyperellular marrow with kappa restricted lymphoplasmacytic lymphoma with pos MYD88 mutation detection. No plasma cell dyscrasia seen. - [MASKED]: CT scans of the chest/abd/pelvis did not demonstrate and adenopathy. Mild splenomegaly 13.2 cm was noted. Renal biopsy was recommended by us to the nephrology team. - [MASKED]: Underwent renal biopsy that demonstrated acute on chronic tubular injury, likely from the patient's known [MASKED] proteinuria. Case was reviewed by hemepath who saw evidence of lymphoplasmacytic lymphoma in the biopsy specimen but this was felt to be a fragment of an inadvertently sampled LN rather than actual renal involvement with lymphoma. Case discussed with Dr [MASKED] recommended treatment of the lymphoma that was causing the ptnuria from acute on chronic tubular injury. This was reflective of the nephrology team consensus. - Given absence of symptomatic systemic lymphoma, it was decide to start treatment with single agent Rituximab. - [MASKED] and [MASKED] rcd 4 weekly doses of Rituxan. - [MASKED]: PET demonstrated no e.o lymphoma or lytic lesions. - [MASKED]: Evaluated by Nephrology and felt to have improvement in ptnuria which was lower at 1.3 compared to [MASKED] previously. Additionally the percent/amount of [MASKED] proteinuria was less than previous values, but not completely negative. However continued to have glycosuria, hypouricemia, and hypophosphatemia indicating continued proximal tubule wasting. With so little [MASKED] protein in the urine, it was unclear if there is ongoing injury with this small amount. - [MASKED]: Case discussed again and felt that we should add Velcade and Dex to the regimen. - [MASKED]: Started on BDR regimen (Velcade/Dex and Rituximab) for treatment of ongoing light chain proximal tubulopathy. Ptn/Creat ratio was 1.6 gm/day before starting Velcade. - Rcd Velcade at 1.3 mg/m2 IV on days 1,[MASKED] and [MASKED]. Tolerated cycle 1 very well with no complications. - [MASKED]: Ptn/creat ration decreased to 1gm/day after cycle 1 of Velcade. Rcd cycle 2 of BDR in which rcd Velcade given at 1.6 mg/m2 and Dex [MASKED] mg along with Rituxan on days 1,[MASKED] and [MASKED]. LFT's were elevated during course of Tx. Lipitor held. - Course complicated by brief episodes of dizziness and diarrhea after Velcade doses for a few hours that resolved by itself. - [MASKED]: Ptn/Creat ratio improved to 0.7 gm/day. Given episodes of hypotension/dizziness post Velcade administration and concern for autonomic neuropathy sec to Velcade , dose of Velcade was reduced to 1.3 mg/m2 and cycle 3 administered. Tolerated well with reduction in dose. - [MASKED]: Ptn/Creat ratio improved to 0.7 gm/day. Given neuropathy,dose of Velcade was reduced further to 0.7 mg/m2 and cycle 4 administered. Tolerated it well with reduction in dose. PAST MEDICAL HISTORY: 1. Small colonic benign adenomatous polyp for which he will have a repeat colonoscopy in [MASKED] years. 2. Obstructive sleep apnea for which he wears a CPAP for the last [MASKED] years. 3. Anxiety, on Celexa. 4. Bilateral hip bursitis. 5. Rare ocular migraines. 6. Hyperlipidemia. 7. Status post appendectomy in [MASKED]. 8. Status post cholecystectomy about five to [MASKED] years ago. 9. New diagnosis of hypertension for which he is on amlodipine. Social History: [MASKED] Family History: Not available as the patient is adopted. Physical Exam: ADMISSION PHYSICAL EXAM ================= VS: Temp 99.2, BP 110/64, HR 71, RR 18, O2 sat 96% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: Alert, oriented, good attention and linear thought, CN [MASKED] intact. Strength full throughout. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM ================== VS: 99.2 Tmax 101.8 at midnight [MASKED] BP 118/76 HR 74 RR 16 97%RA GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Lungs CTA bilaterally. No wheezing, rales or rhonchi. ABD: NABS. Abd soft, nontender, nondistended, no hepatomegaly, no splenomegaly. No rebound or guarding. EXT: Warm, well perfused,2+ DP pulses NEURO: Alert, oriented, good attention and linear thought, CN [MASKED] intact. Strength full throughout. SKIN: No significant rashes. Pertinent Results: LABS ON ADMISSION ============= [MASKED] 10:20AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] Im [MASKED] [MASKED] [MASKED] 10:20AM BLOOD Plt [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] 10:20AM BLOOD [MASKED] B [MASKED] [MASKED] NOTABLE LABS ========= [MASKED] 10:20AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 05:21PM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] Im [MASKED] [MASKED] [MASKED] 05:21PM BLOOD [MASKED] [MASKED] Im [MASKED] [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] 05:21PM BLOOD [MASKED] [MASKED] [MASKED] 07:03PM BLOOD [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 10:20AM BLOOD [MASKED] B [MASKED] [MASKED] [MASKED] 05:32PM BLOOD [MASKED] [MASKED] 08:16PM BLOOD [MASKED] [MASKED] 07:11AM BLOOD [MASKED] LABS ON DISCHARGE ============= [MASKED] 06:40AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 05:21PM BLOOD [MASKED] [MASKED] Im [MASKED] [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 05:21PM BLOOD [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED]:11AM BLOOD [MASKED] IMAGING ====== CXR PA & LATERAL ([MASKED]) FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. Hilar contours are stable. IMPRESSION: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICROBIOLOGY ========== GENERAL URINE INFORMATION Urine ColorYellow W Urine AppearanceClear W Specific Gravity1.0281.001 - 1.035W DIPSTICK URINALYSIS BloodSM W NitriteNEG W Protein100 mg/dLW Glucose300 mg/dLW KetoneNEG mg/dLW BilirubinNEG mg/dLW UrobilinogenNEG0.2 - 1mg/dLW pH6.05 - 8unitsW LeukocytesNEG W MICROSCOPIC URINE EXAMINATION RBC10 - 2#/hpfW WBC10 - 5#/hpfW BacteriaNONE W YeastNONE W Epithelial Cells<1 #/hpfW URINE CASTS Hyaline Casts2*0 - 0#/lpfW OTHER URINE FINDINGS Urine MucousRARE W [MASKED] 7:03 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 5:21 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 7:44 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 5:45 pm Rapid Respiratory Viral Screen & Culture 3. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. [MASKED] [MASKED] 12:00 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [MASKED] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of lymphoplasmacytic lymphoma and IgG kappa MGUS c/b kidney injury now C5D18 (treated day prior to admission) BDR (bortezomib, dexamethasone, rituxan) who presented with fever and leukocytosis. During the course of his hospital stay, the following issues were addressed: # Fever/Cough: Patient with fever and URI symptoms most likely consistent with viral infection. Influenza and Respiratory viral screen were negative. CXR with no active infiltrate. Lactate was initially elevated at 3.1 but downtrended overnight with IVF to 1.6 on discharge. Patient was discharged with a [MASKED] course of azithromycin for empiric coverage of possible bacterial superinfection. # Transaminitis: Initial ALT 133 and AST 128, ALP 174 (but specimen hemolyzed). Immediate [MASKED] labs with ALT of 103, AST 68, andALP 151. Overnight there was a slight improvement with ALT of 97, AST 56 and ALP 149 coinciding with IV fluid administration, Patient has had intermittent transaminitis in past and has never had bx per OMR. ALT and AST down from admission with fluid administration. # Leukocytosis: WBC 26.7 on admission. Secondary to infection as above vs. steroids received yesterday with chemotherapy. Downtrended to 12.9 on discharge. # [MASKED] on CKD: Patient presented with Cr 1.8 up from baseline 1.5. Improved after IVF to baseline. Creatinine on discharge was 1.6. # Hypertension. Held lisinopril in setting of [MASKED]. Normotensive during hospital stay. # Anxiety. Continued citalopram. Continued Ativan prn. TRANSITIONAL ISSUES ============== - Azithromycin 5 day course (Start [MASKED] | End [MASKED] - Holding lisinopril due to [MASKED] (Cr at discharge at baseline of 1.6). Will need to be restarted with primary oncologist/PCP - [MASKED] viral culture pending - If patient spikes fevers during next cycle of BDR, then we know this is more likely a reaction to chemotherapy. - Transaminitis: Patient has had intermittent transaminitis in past; has never had bx. ALT and AST down from admission with fluid administration. Consider further [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO BID 2. Lisinopril 2.5 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Dapsone 100 mg PO DAILY 5. LORazepam 0.5 mg PO QHS:PRN insomnia 6. Pantoprazole 40 mg PO Q24H 7. Prochlorperazine 10 mg PO Q8H:PRN nausea/vomiting 8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 9. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Days RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*3 Tablet Refills:*0 2. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 3. GuaiFENesin [MASKED] mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL [MASKED] ml by mouth Q6 Refills:*0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Acyclovir 400 mg PO BID 6. Citalopram 20 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. LORazepam 0.5 mg PO QHS:PRN insomnia 10. Pantoprazole 40 mg PO Q24H 11. Prochlorperazine 10 mg PO Q8H:PRN nausea/vomiting 12. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until you discuss with your primary oncologist Discharge Disposition: Home Discharge Diagnosis: Primary ===== Lymphoplasmacytic lymphoma with IgG kappa MGUS URI Acute on Chronic Kidney Disease Secondary ======= Hypertension Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], It was a pleasure caring for you here at [MASKED]. You presented with a fever of 100.8 , cough and 3 days of vomiting. You did well in the hospital and were discharged with a [MASKED] course of antibiotics to cover for a possible bacterial infection on top of what is likely a viral respiratory infection. Please take azithromycin for 3 more days and do not take your lisinopril until discussing with Dr. [MASKED]. If you experience any of the danger signs below, please contact your oncologist or come to the emergency department. Best Wishes, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "I129", "N189", "G4733", "F419" ]
[ "J069: Acute upper respiratory infection, unspecified", "N179: Acute kidney failure, unspecified", "C8309: Small cell B-cell lymphoma, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "F419: Anxiety disorder, unspecified", "D72828: Other elevated white blood cell count", "R803: Bence Jones proteinuria" ]
10,061,737
25,469,970
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ Successful post-pyloric advancement of a Dobhoff feeding tube. History of Present Illness: Ms. ___ is a ___ PMHx R-sided nephrectomy, cholelithiasis, COPD, and HTN who is transferred from ___ ___ for ERCP evaluation. She presented to ___ this morning for acute onset RUQ abdominal pain and nausea with multiple episodes emesis this morning; it is unclear if her emesis was bilious/bloody as the patient is blind. She had otherwise been in her USOH. Her HR was initially in the ___ upon arrival, felt to be ___ too much beta-blockade from her home metoprolol but she was HD stable and asymptomatic. At ___, her labs were notable for WBC 8.6, Hgb 15.5, Plt 243, Na 144, BUN 17, Cr 1.5. AST 46, ALT 43, Alk Phos 85, Tbili 0.8, DBili 0.3, INR 0.9. Lactate 2.2. Trop < 0.02, lipase elevated to 436. EKG there showed sinus bradycardia. CXR wnl. RUQ US there showed dilated CBD with cholelithiasis. She received cipro/flagyl and was subsequently transferred to ___ for ERCP evaluation. Upon arrival here, VSS without any fever and HR in the ___. ERCP recommended MRCP. The patient received Unasyn x 1 prior to transfer. Past Medical History: R-sided nephrectomy over ___ years ago (daughter says it was due to congenital issue and that kidney was not working) cholelithiasis HTN COPD Social History: ___ Family History: No history of biliary disease. Physical Exam: Admission Physical Exam: Vitals- 99.0 183 / 72 60 18 94 2l NC GENERAL: AOx3, NAD HEENT: MMdry, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: CTAB, no w/r/r, unlabored respirations ABDOMEN: soft, nondistended, moderate TTP of RUQ and epigastrium without rebound/guarding, + bowel sounds EXTREMITIES: no significant pitting edema of BLE GU: Foley in place SKIN: no rash or lesions NEUROLOGIC: AOx2 (to self and month/year, able to name ___ unable to say she was at ___ and state specific date), moving all extremities, fluent speech, following commands. Discharge Physical Exam: VS: 97.5, 128/66, 69, 24, 95% Ra Gen: Frail elderly woman sitting in chair in NAD CV: RRR, nml S1 and S2, no m/r/g Pulm: CTAB, no w/r/r, unlabored respirations Abd: soft, NT/ND Ext: WWP no edema Pertinent Results: ___ 06:37AM BLOOD WBC-9.0 RBC-4.31 Hgb-12.4 Hct-39.3 MCV-91 MCH-28.8 MCHC-31.6* RDW-14.2 RDWSD-47.1* Plt ___ ___ 06:50AM BLOOD WBC-9.1 RBC-4.50 Hgb-12.9 Hct-40.3 MCV-90 MCH-28.7 MCHC-32.0 RDW-14.1 RDWSD-45.3 Plt ___ ___ 06:35AM BLOOD WBC-8.8 RBC-4.68 Hgb-13.8 Hct-41.5 MCV-89 MCH-29.5 MCHC-33.3 RDW-13.8 RDWSD-43.9 Plt ___ ___ 10:20AM BLOOD WBC-9.0 RBC-4.57 Hgb-13.3 Hct-40.6 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.8 RDWSD-44.4 Plt ___ ___ 06:44AM BLOOD WBC-8.5 RBC-4.54 Hgb-13.2 Hct-40.7 MCV-90 MCH-29.1 MCHC-32.4 RDW-13.3 RDWSD-44.2 Plt ___ ___ 07:10AM BLOOD WBC-8.7 RBC-4.44 Hgb-12.8 Hct-40.5 MCV-91 MCH-28.8 MCHC-31.6* RDW-13.4 RDWSD-44.7 Plt ___ ___ 06:35AM BLOOD WBC-10.2* RBC-4.49 Hgb-13.3 Hct-41.1 MCV-92 MCH-29.6 MCHC-32.4 RDW-13.8 RDWSD-46.5* Plt ___ ___ 07:10AM BLOOD WBC-8.9 RBC-4.46 Hgb-13.0 Hct-40.2 MCV-90 MCH-29.1 MCHC-32.3 RDW-13.5 RDWSD-45.1 Plt ___ ___ 08:50PM BLOOD WBC-9.0 RBC-4.84 Hgb-14.2 Hct-43.3 MCV-90 MCH-29.3 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt ___ ___ 06:40AM BLOOD WBC-8.5 RBC-5.14 Hgb-14.9 Hct-45.5* MCV-89 MCH-29.0 MCHC-32.7 RDW-13.3 RDWSD-43.4 Plt ___ ___ 07:10AM BLOOD ___ PTT-28.5 ___ ___ 06:40AM BLOOD ___ PTT-27.6 ___ ___ 06:37AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-141 K-4.5 Cl-106 HCO3-22 AnGap-18 ___ 06:50AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-140 K-4.3 Cl-104 HCO3-22 AnGap-18 ___ 06:35AM BLOOD Glucose-134* UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 ___ 10:20AM BLOOD Glucose-131* UreaN-13 Creat-0.8 Na-135 K-4.1 Cl-102 HCO3-23 AnGap-14 ___ 06:44AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-137 K-4.4 Cl-108 HCO3-21* AnGap-12 ___ 07:10AM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-139 K-4.3 Cl-108 HCO3-24 AnGap-11 ___ 06:35AM BLOOD Glucose-116* UreaN-21* Creat-1.0 Na-141 K-3.7 Cl-106 HCO3-27 AnGap-12 ___ 07:10AM BLOOD Glucose-108* UreaN-23* Creat-1.3* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 ___ 08:50PM BLOOD Glucose-127* UreaN-22* Creat-1.4* Na-140 K-4.0 Cl-105 HCO3-24 AnGap-15 ___ 06:40AM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-145 K-4.2 Cl-107 HCO3-25 AnGap-17 ___ 08:50PM BLOOD ALT-27 AST-27 AlkPhos-64 TotBili-1.8* ___ 06:40AM BLOOD ALT-33 AST-33 AlkPhos-70 TotBili-1.2 ___ 06:37AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.1 ___ 06:50AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 ___ 06:35AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1 ___ 10:20AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8 ___ 06:44AM BLOOD Calcium-7.5* Phos-1.7* Mg-2.2 ___ 07:10AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.7 ___ 06:35AM BLOOD Calcium-8.1* Phos-1.8* Mg-1.8 ___ 07:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6 ___ 06:40AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.7 ___ 09:00PM BLOOD Lactate-2.0 RADIOLOGY: ___ MRCP: 1. Cholelithiasis with marked surrounding inflammation and loculated fluid centered around the gallbladder. The gallbladder is only moderately distended for the degree of inflammation and there is irregularity and discontinuity of its wall at the fundus which are findings concerning for perforated acute cholecystitis. 2. No choledocholithiasis. 3. Large paraduodenal diverticulum measuring 3.1 cm ___ CT A/P: 1. Normal appearing gallbladder without evidence of acute cholecystitis. 2. Extra luminal retroperitoneal gas lateral and posterior to the second portion of the duodenum extending superiorly into the porta hepatis with minimal retroperitoneal and right perinephric free fluid suggestive of a localized duodenal perforation. ___ CXR: Sequential images demonstrate advancement of a nasogastric tube into the stomach. ___ Upper GI Series: A Dobhoff tube is noted. Water-soluble contrast (Gastrografin) was administered through the nasogastric tube. Gastrografin was seen to pass into the duodenum from the stomach, filling the previously noted diverticulum of the second portion of the duodenum. In subsequent images contrast empties from the diverticulum into the more distal bowel without evidence of extraluminal contrast or leak. MICROBIOLOGY: ___ 4:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). Brief Hospital Course: Ms. ___ is a ___ F PMHx R-sided nephrectomy, cholelithiasis, and HTN who is transferred from ___ ___ for ERCP evaluation for possible biliary obstruction. She was initially admitted to medicine service with concern for cholelithiasis with biliary obstruction. Endoscopy showed cholelithiasis with surrounding inflammation concerning for perforated acute cholecystitis. A large paradodenal diverticulum was also seen measuring 3.___bdomen pelvis was obtained that showed duodenal diverticulitis with pockets of gas. Nasogastric tube was placed and she was admitted to the Acute Care Surgery Service for further management of duodenal perforation. On HD4 doboff feeding tube was placed and advanced to post pyloric and post site of perforation on HD5. Once placement confirmed, tube feeds were started and titrated to goal. Abdominal pain was monitored and decreased. Nasogastic tube was maintained on low wall suction and post pyloric tube feeds were advanced to goal with good tolerability. She initially had multiple loose bowel movements negative for c. diff. On HD10 a repeat upper GI contrast study was obtained and showed no evidence of leak. The nasogastric tube was subsequently discontinued and she was given an oral diet. Calorie counts were monitored and once adequate PO intake was obtain, feeding tube was discontinued. On HD12 antibiotics were discontinued. She was seen and evaluated by physical therapy who recommended ___ rehabilitation to regain her strength and endurance. 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 on HD17, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assist, voiding without assistance, and denied pain. The patient was discharged to rehab. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Heparin 5000 UNIT SC BID 3. LOPERamide 2 mg PO QID:PRN diarrhea/loose stools 4. Pantoprazole 40 mg PO Q24H 5. TraZODone 25 mg PO QHS:PRN insomnia 6. amLODIPine 2.5 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q ___ prn wheeze 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Perforated duodenal diverticulum 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 Acute Care Surgery Service on ___ with a perforation in your intestine caused by and infection called diverticulitis. You were given bowel rest and antibiotics. You had a feeding tube placed past the point of injury to continue your nutrition. Once you abdominal pain subsided, repeat imaging was done that showed the injury healed. Your diet was advanced and your nutritional intake was recorded. Once you were able to meet your caloric intake needs, the feeding tube was removed. You are now doing better, tolerating a regular diet, and you are not having any sings or symptoms of infection. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Followup Instructions: ___
[ "K5700", "G92", "N179", "E46", "R001", "I10", "Z905", "J449", "Z87891", "T404X5A", "Y92239", "K8020", "Z6826", "R197" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] Successful post-pyloric advancement of a Dobhoff feeding tube. History of Present Illness: Ms. [MASKED] is a [MASKED] PMHx R-sided nephrectomy, cholelithiasis, COPD, and HTN who is transferred from [MASKED] [MASKED] for ERCP evaluation. She presented to [MASKED] this morning for acute onset RUQ abdominal pain and nausea with multiple episodes emesis this morning; it is unclear if her emesis was bilious/bloody as the patient is blind. She had otherwise been in her USOH. Her HR was initially in the [MASKED] upon arrival, felt to be [MASKED] too much beta-blockade from her home metoprolol but she was HD stable and asymptomatic. At [MASKED], her labs were notable for WBC 8.6, Hgb 15.5, Plt 243, Na 144, BUN 17, Cr 1.5. AST 46, ALT 43, Alk Phos 85, Tbili 0.8, DBili 0.3, INR 0.9. Lactate 2.2. Trop < 0.02, lipase elevated to 436. EKG there showed sinus bradycardia. CXR wnl. RUQ US there showed dilated CBD with cholelithiasis. She received cipro/flagyl and was subsequently transferred to [MASKED] for ERCP evaluation. Upon arrival here, VSS without any fever and HR in the [MASKED]. ERCP recommended MRCP. The patient received Unasyn x 1 prior to transfer. Past Medical History: R-sided nephrectomy over [MASKED] years ago (daughter says it was due to congenital issue and that kidney was not working) cholelithiasis HTN COPD Social History: [MASKED] Family History: No history of biliary disease. Physical Exam: Admission Physical Exam: Vitals- 99.0 183 / 72 60 18 94 2l NC GENERAL: AOx3, NAD HEENT: MMdry, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: CTAB, no w/r/r, unlabored respirations ABDOMEN: soft, nondistended, moderate TTP of RUQ and epigastrium without rebound/guarding, + bowel sounds EXTREMITIES: no significant pitting edema of BLE GU: Foley in place SKIN: no rash or lesions NEUROLOGIC: AOx2 (to self and month/year, able to name [MASKED] unable to say she was at [MASKED] and state specific date), moving all extremities, fluent speech, following commands. Discharge Physical Exam: VS: 97.5, 128/66, 69, 24, 95% Ra Gen: Frail elderly woman sitting in chair in NAD CV: RRR, nml S1 and S2, no m/r/g Pulm: CTAB, no w/r/r, unlabored respirations Abd: soft, NT/ND Ext: WWP no edema Pertinent Results: [MASKED] 06:37AM BLOOD WBC-9.0 RBC-4.31 Hgb-12.4 Hct-39.3 MCV-91 MCH-28.8 MCHC-31.6* RDW-14.2 RDWSD-47.1* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-9.1 RBC-4.50 Hgb-12.9 Hct-40.3 MCV-90 MCH-28.7 MCHC-32.0 RDW-14.1 RDWSD-45.3 Plt [MASKED] [MASKED] 06:35AM BLOOD WBC-8.8 RBC-4.68 Hgb-13.8 Hct-41.5 MCV-89 MCH-29.5 MCHC-33.3 RDW-13.8 RDWSD-43.9 Plt [MASKED] [MASKED] 10:20AM BLOOD WBC-9.0 RBC-4.57 Hgb-13.3 Hct-40.6 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.8 RDWSD-44.4 Plt [MASKED] [MASKED] 06:44AM BLOOD WBC-8.5 RBC-4.54 Hgb-13.2 Hct-40.7 MCV-90 MCH-29.1 MCHC-32.4 RDW-13.3 RDWSD-44.2 Plt [MASKED] [MASKED] 07:10AM BLOOD WBC-8.7 RBC-4.44 Hgb-12.8 Hct-40.5 MCV-91 MCH-28.8 MCHC-31.6* RDW-13.4 RDWSD-44.7 Plt [MASKED] [MASKED] 06:35AM BLOOD WBC-10.2* RBC-4.49 Hgb-13.3 Hct-41.1 MCV-92 MCH-29.6 MCHC-32.4 RDW-13.8 RDWSD-46.5* Plt [MASKED] [MASKED] 07:10AM BLOOD WBC-8.9 RBC-4.46 Hgb-13.0 Hct-40.2 MCV-90 MCH-29.1 MCHC-32.3 RDW-13.5 RDWSD-45.1 Plt [MASKED] [MASKED] 08:50PM BLOOD WBC-9.0 RBC-4.84 Hgb-14.2 Hct-43.3 MCV-90 MCH-29.3 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-8.5 RBC-5.14 Hgb-14.9 Hct-45.5* MCV-89 MCH-29.0 MCHC-32.7 RDW-13.3 RDWSD-43.4 Plt [MASKED] [MASKED] 07:10AM BLOOD [MASKED] PTT-28.5 [MASKED] [MASKED] 06:40AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 06:37AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-141 K-4.5 Cl-106 HCO3-22 AnGap-18 [MASKED] 06:50AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-140 K-4.3 Cl-104 HCO3-22 AnGap-18 [MASKED] 06:35AM BLOOD Glucose-134* UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 [MASKED] 10:20AM BLOOD Glucose-131* UreaN-13 Creat-0.8 Na-135 K-4.1 Cl-102 HCO3-23 AnGap-14 [MASKED] 06:44AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-137 K-4.4 Cl-108 HCO3-21* AnGap-12 [MASKED] 07:10AM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-139 K-4.3 Cl-108 HCO3-24 AnGap-11 [MASKED] 06:35AM BLOOD Glucose-116* UreaN-21* Creat-1.0 Na-141 K-3.7 Cl-106 HCO3-27 AnGap-12 [MASKED] 07:10AM BLOOD Glucose-108* UreaN-23* Creat-1.3* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 [MASKED] 08:50PM BLOOD Glucose-127* UreaN-22* Creat-1.4* Na-140 K-4.0 Cl-105 HCO3-24 AnGap-15 [MASKED] 06:40AM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-145 K-4.2 Cl-107 HCO3-25 AnGap-17 [MASKED] 08:50PM BLOOD ALT-27 AST-27 AlkPhos-64 TotBili-1.8* [MASKED] 06:40AM BLOOD ALT-33 AST-33 AlkPhos-70 TotBili-1.2 [MASKED] 06:37AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.1 [MASKED] 06:50AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 [MASKED] 06:35AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1 [MASKED] 10:20AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8 [MASKED] 06:44AM BLOOD Calcium-7.5* Phos-1.7* Mg-2.2 [MASKED] 07:10AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.7 [MASKED] 06:35AM BLOOD Calcium-8.1* Phos-1.8* Mg-1.8 [MASKED] 07:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6 [MASKED] 06:40AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.7 [MASKED] 09:00PM BLOOD Lactate-2.0 RADIOLOGY: [MASKED] MRCP: 1. Cholelithiasis with marked surrounding inflammation and loculated fluid centered around the gallbladder. The gallbladder is only moderately distended for the degree of inflammation and there is irregularity and discontinuity of its wall at the fundus which are findings concerning for perforated acute cholecystitis. 2. No choledocholithiasis. 3. Large paraduodenal diverticulum measuring 3.1 cm [MASKED] CT A/P: 1. Normal appearing gallbladder without evidence of acute cholecystitis. 2. Extra luminal retroperitoneal gas lateral and posterior to the second portion of the duodenum extending superiorly into the porta hepatis with minimal retroperitoneal and right perinephric free fluid suggestive of a localized duodenal perforation. [MASKED] CXR: Sequential images demonstrate advancement of a nasogastric tube into the stomach. [MASKED] Upper GI Series: A Dobhoff tube is noted. Water-soluble contrast (Gastrografin) was administered through the nasogastric tube. Gastrografin was seen to pass into the duodenum from the stomach, filling the previously noted diverticulum of the second portion of the duodenum. In subsequent images contrast empties from the diverticulum into the more distal bowel without evidence of extraluminal contrast or leak. MICROBIOLOGY: [MASKED] 4:45 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). Brief Hospital Course: Ms. [MASKED] is a [MASKED] F PMHx R-sided nephrectomy, cholelithiasis, and HTN who is transferred from [MASKED] [MASKED] for ERCP evaluation for possible biliary obstruction. She was initially admitted to medicine service with concern for cholelithiasis with biliary obstruction. Endoscopy showed cholelithiasis with surrounding inflammation concerning for perforated acute cholecystitis. A large paradodenal diverticulum was also seen measuring 3. bdomen pelvis was obtained that showed duodenal diverticulitis with pockets of gas. Nasogastric tube was placed and she was admitted to the Acute Care Surgery Service for further management of duodenal perforation. On HD4 doboff feeding tube was placed and advanced to post pyloric and post site of perforation on HD5. Once placement confirmed, tube feeds were started and titrated to goal. Abdominal pain was monitored and decreased. Nasogastic tube was maintained on low wall suction and post pyloric tube feeds were advanced to goal with good tolerability. She initially had multiple loose bowel movements negative for c. diff. On HD10 a repeat upper GI contrast study was obtained and showed no evidence of leak. The nasogastric tube was subsequently discontinued and she was given an oral diet. Calorie counts were monitored and once adequate PO intake was obtain, feeding tube was discontinued. On HD12 antibiotics were discontinued. She was seen and evaluated by physical therapy who recommended [MASKED] rehabilitation to regain her strength and endurance. 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 on HD17, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assist, voiding without assistance, and denied pain. The patient was discharged to rehab. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Heparin 5000 UNIT SC BID 3. LOPERamide 2 mg PO QID:PRN diarrhea/loose stools 4. Pantoprazole 40 mg PO Q24H 5. TraZODone 25 mg PO QHS:PRN insomnia 6. amLODIPine 2.5 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q [MASKED] prn wheeze 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Perforated duodenal diverticulum 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 Acute Care Surgery Service on [MASKED] with a perforation in your intestine caused by and infection called diverticulitis. You were given bowel rest and antibiotics. You had a feeding tube placed past the point of injury to continue your nutrition. Once you abdominal pain subsided, repeat imaging was done that showed the injury healed. Your diet was advanced and your nutritional intake was recorded. Once you were able to meet your caloric intake needs, the feeding tube was removed. You are now doing better, tolerating a regular diet, and you are not having any sings or symptoms of infection. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Followup Instructions: [MASKED]
[]
[ "N179", "I10", "J449", "Z87891" ]
[ "K5700: Diverticulitis of small intestine with perforation and abscess without bleeding", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "E46: Unspecified protein-calorie malnutrition", "R001: Bradycardia, unspecified", "I10: Essential (primary) hypertension", "Z905: Acquired absence of kidney", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "T404X5A: Poisoning by, adverse effect of and underdosing of other synthetic narcotics", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "R197: Diarrhea, unspecified" ]
10,062,203
21,070,114
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenergan / Lyrica / Cymbalta / Bactrim Attending: ___. Chief Complaint: abdominal ___ Major Surgical or Invasive Procedure: ___ ERCP with sphincterotomy, brushings History of Present Illness: HPI: The patient is a ___ female w/PMHx including chronic pancreatitis s/p Puestow procedure with chronic abdominal ___, now presenting for observation after ERCP performed for ampullary stenosis. The patient describes chronic abdominal ___ for ___ years. No recent changes. It's LLQ, constant, steady, ___ like a weight with radiation through to her back, with intermittent exacerbations without clear cause that last ___ days with ___ going up to ___ sometimes ___ that resolve without clear reason, associated with nausea, yellow/green vomiting up to 4x a day and diarrhea "foamy" during these episodes. Seen post-procedure, she's doing ok. A bit of soreness, but no significant change from her chronic pre-procedure ___. We review her situation and I answer all her questions. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Primary Care Provider: ___, MD ___ providers: - ___ Neurological, possibly "___ P. ___, M.D." -- h t t p : / / w w w . n eneuro.com/our-physicians/physicians/___-m-d/ - GI at ___, Dr. ___ ___ Medical History: Chronic pancreatitis s/p distal pancreatectomy and Puestow Chronic abdominal ___ COPD HL Fatty liver Diabetes mellitus w/neuropathy and retinopathy Peptic ulcer disease GERD Seizure disorder Legally blind ? History of submucosal antral mass on endoscopic ultrasound Social History: ___ Family History: No pancreatic disease. Mother died of lung cancer. Son with hyperlipidemia with a triglyceride level of 700. Hypertension Physical Exam: Admission Exam VS: T 97.9, BP 127/76, HR 65, RR 16, O2 sat 96% on RA Lines/tubes: PIV Gen: older woman lying in bed, alert, cooperative, NAD HEENT: anicteric, PERRL, MMM Chest: equal chest rise, fair air movement bilat posteriorly, no WOB or cough Cardiovasc: RRR, no m/r/g Abd: decr b.s., well healed scars consistent with surgery mentioned above, soft, NTND Extr: WWP, no edema Skin: no rashes on limited exam Neuro: CN II-XII intact (IX and X not specifically tested), strength ___ throughout, sensation to light touch throughout, gait deferred Psych: normal affect Pertinent Results: ___ 10:30AM UREA N-12 CREAT-0.8 SODIUM-144 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 ___ 10:30AM estGFR-Using this ___ 10:30AM ALT(SGPT)-23 AST(SGOT)-47* ALK PHOS-302* AMYLASE-22 TOT BILI-0.4 ___ 10:30AM LIPASE-14 ___ 10:30AM MAGNESIUM-2.2 ___ 10:30AM WBC-5.5 RBC-4.62 HGB-12.8 HCT-39.5 MCV-86 MCH-27.7 MCHC-32.4 RDW-13.8 RDWSD-42.8 ___ 10:30AM PLT COUNT-157 ___ 10:30AM ___ PTT-64.0* ___ PROCEDURES ___ ERCP Impression: •Limited exam of the esophagus was normal •Limited exam of the stomach was normal •Limited exam of the duodenum was normal •The scout film revealed surgical clips in the RUQ. •The major papilla appeared normal. •The CBD was successfully cannulated with the Hydratome sphincterotome preloaded with a 0.035in guidewire. •The guidewire was advanced into the intrahepatic biliary tree. •Contrast injection revealed a severely dilated CBD to a maximum diameter of approximately 20mm with smooth tapering to the level of the ampulla. •No discrete filling defects, strictures or masses were noted. •The intrahepatic biliary tree appeared normal. •A sphincterotomy was successfully performed at the 12 o'clock position. •No post sphincterotomy bleeding was noted. •The CBD was swept several times yielding clear bile. •Brushings were successfully obtained from distal CBD/ampulla and sample sent for cytology. •There excellent spontaneous drainage of bile and contrast at the end of the procedure. •The pancreatic duct was partially filled with contrast and visualized proximally. •The course and caliber of the duct was irregular but no discrete filling defects were noted. Recommendations: •Admit to hospital for monitoring •NPO overnight with aggressive IV hydration with LR at 200 cc/hr •If no abdominal ___ in the morning, advance diet to clear liquids and then advance as tolerated •No aspirin, Plavix, NSAIDS, Coumadin for 5 days. •Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days. •Follow up with cytology reports. Please call Dr. ___ ___ in 7 days for the pathology results. •Further recommendations based on cytology results. If cytology results are negative then will recommend EUS. •Follow for response and complications. If any abdominal ___, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ___ DISCHARGE LABS Brief Hospital Course: ___ yo woman w/PMHx including chronic pancreatitis s/p distal pancreatectomy and Puestow with chronic abdominal ___, now with ampullary stricture leading to severe CBD dilation, s/p ___ ERCP with post procedure acute on chronic epigastric ___ and hypoglycemia #Ampullary stricture/stenosis: #post ERCP acute on chronic pancreatitis: Leading to severe CBD dilation in the setting of chronic pancreatitis s/p distal pancreatectomy and Puestow. Now s/p ERCP with sphincterotomy. Procedure went well but she had acute post procedure ___ consistent with acute on chronic pancreatitis. Per history, this was typical for her post ERCP and acute symptoms typically last several days. She was managed with supportive care and IV/PO analgesia with eventual improvement in her symptoms. She completed 5 days of Cipro. her bx was negative. She was discharged on her home methadone and a short course of oxycodone to taper over 5 days. PMP reviewed. She has a ___ clinic appointment and was encouraged to follow up with Dr. ___. #Hypoglycemia/DM with neuropathy: Initially hypoglycemic in setting of NPO status and insulin administration to ___. Required D5 and D10. This was likely related to Lantus in the setting of her being NPO. Once she began eating her FSBG improved but maintained in the 100-low 200s. Thus, she was discharged OFF her lantus and ISS alone, pending follow up with her PCP. #Coagulopathy with h/o fatty liver disease: Improved slightly after dose of vitamin K - unclear etiology, suspect related to liver disease given mildly low albumin +/- nutritional component #Chronic abdominal ___ - continue home methadone TID, use oxycodone for breakthrough ___ post procedure on short term basis - ___ clinic follow up arranged #COPD - used fluticasone-salmeterol here (don't have Symbicort on formulary), as well as PRN albuterol #Peptic ulcer disease, GERD - continued home PPI #Seizure disorder - lamotrigine, levetiracetam, topiramate #Legally blind Advance Care Planning: Health Care Proxy: will designate her husband, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 200 mg PO DAILY 2. LevETIRAcetam 1500 mg PO BID 3. LamoTRIgine 400 mg PO QPM 4. Topiramate (Topamax) 100 mg PO BID 5. Omeprazole 40 mg PO DAILY 6. Gemfibrozil 600 mg PO BID 7. Glargine 55 Units Breakfast Glargine 55 Units Bedtime Insulin SC Sliding Scale using glulisine Insulin 8. Furosemide 40 mg PO DAILY:PRN swelling 9. Methadone 20 mg PO QAM 10. Methadone 15 mg PO BID 11. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY 12. Aspirin 81 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN ___ - Moderate short term, PMP reviewed. taper as directed RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*13 Tablet Refills:*0 3. Senna 17.2 mg PO QHS 4. Insulin SC Sliding Scale Fingerstick QACHS, 3AM Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY 7. Furosemide 40 mg PO DAILY:PRN swelling 8. Gemfibrozil 600 mg PO BID 9. LamoTRIgine 200 mg PO DAILY 10. LamoTRIgine 400 mg PO QPM 11. LevETIRAcetam 1500 mg PO BID 12. Methadone 20 mg PO QAM 13. Methadone 15 mg PO BID 14. Omeprazole 40 mg PO DAILY 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing 16. Topiramate (Topamax) 100 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Chronic ___ Dm2 COPD Sz disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for monitoring post ERCP. Post ERCP you developed acute abdominal ___ which is now improving. your biopsy was negative. Please continue a low fat diet and stay well hydrated. Please follow up closely with your PCP, ___. ___ the ___ clinic. As we discussed, avoid alcohol and driving while taking oxycodone, and please taper as prescribed. Given your recent low blood sugars, you are being discharged OFF your lantus. Please check your blood glucose 4 times per day with sliding scale. Please follow up with your PCP regarding starting your Lantus. Followup Instructions: ___
[ "K8590", "K831", "E1140", "D684", "K861", "K838", "E11319", "E11649", "G8929", "J449", "G40909", "K760", "H548", "K219", "R1013", "Z794", "Z8711", "Z87891" ]
Allergies: Phenergan / Lyrica / Cymbalta / Bactrim Chief Complaint: abdominal [MASKED] Major Surgical or Invasive Procedure: [MASKED] ERCP with sphincterotomy, brushings History of Present Illness: HPI: The patient is a [MASKED] female w/PMHx including chronic pancreatitis s/p Puestow procedure with chronic abdominal [MASKED], now presenting for observation after ERCP performed for ampullary stenosis. The patient describes chronic abdominal [MASKED] for [MASKED] years. No recent changes. It's LLQ, constant, steady, [MASKED] like a weight with radiation through to her back, with intermittent exacerbations without clear cause that last [MASKED] days with [MASKED] going up to [MASKED] sometimes [MASKED] that resolve without clear reason, associated with nausea, yellow/green vomiting up to 4x a day and diarrhea "foamy" during these episodes. Seen post-procedure, she's doing ok. A bit of soreness, but no significant change from her chronic pre-procedure [MASKED]. We review her situation and I answer all her questions. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Primary Care Provider: [MASKED], MD [MASKED] providers: - [MASKED] Neurological, possibly "[MASKED] P. [MASKED], M.D." -- h t t p : / / w w w . n eneuro.com/our-physicians/physicians/[MASKED]-m-d/ - GI at [MASKED], Dr. [MASKED] [MASKED] Medical History: Chronic pancreatitis s/p distal pancreatectomy and Puestow Chronic abdominal [MASKED] COPD HL Fatty liver Diabetes mellitus w/neuropathy and retinopathy Peptic ulcer disease GERD Seizure disorder Legally blind ? History of submucosal antral mass on endoscopic ultrasound Social History: [MASKED] Family History: No pancreatic disease. Mother died of lung cancer. Son with hyperlipidemia with a triglyceride level of 700. Hypertension Physical Exam: Admission Exam VS: T 97.9, BP 127/76, HR 65, RR 16, O2 sat 96% on RA Lines/tubes: PIV Gen: older woman lying in bed, alert, cooperative, NAD HEENT: anicteric, PERRL, MMM Chest: equal chest rise, fair air movement bilat posteriorly, no WOB or cough Cardiovasc: RRR, no m/r/g Abd: decr b.s., well healed scars consistent with surgery mentioned above, soft, NTND Extr: WWP, no edema Skin: no rashes on limited exam Neuro: CN II-XII intact (IX and X not specifically tested), strength [MASKED] throughout, sensation to light touch throughout, gait deferred Psych: normal affect Pertinent Results: [MASKED] 10:30AM UREA N-12 CREAT-0.8 SODIUM-144 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 [MASKED] 10:30AM estGFR-Using this [MASKED] 10:30AM ALT(SGPT)-23 AST(SGOT)-47* ALK PHOS-302* AMYLASE-22 TOT BILI-0.4 [MASKED] 10:30AM LIPASE-14 [MASKED] 10:30AM MAGNESIUM-2.2 [MASKED] 10:30AM WBC-5.5 RBC-4.62 HGB-12.8 HCT-39.5 MCV-86 MCH-27.7 MCHC-32.4 RDW-13.8 RDWSD-42.8 [MASKED] 10:30AM PLT COUNT-157 [MASKED] 10:30AM [MASKED] PTT-64.0* [MASKED] PROCEDURES [MASKED] ERCP Impression: •Limited exam of the esophagus was normal •Limited exam of the stomach was normal •Limited exam of the duodenum was normal •The scout film revealed surgical clips in the RUQ. •The major papilla appeared normal. •The CBD was successfully cannulated with the Hydratome sphincterotome preloaded with a 0.035in guidewire. •The guidewire was advanced into the intrahepatic biliary tree. •Contrast injection revealed a severely dilated CBD to a maximum diameter of approximately 20mm with smooth tapering to the level of the ampulla. •No discrete filling defects, strictures or masses were noted. •The intrahepatic biliary tree appeared normal. •A sphincterotomy was successfully performed at the 12 o'clock position. •No post sphincterotomy bleeding was noted. •The CBD was swept several times yielding clear bile. •Brushings were successfully obtained from distal CBD/ampulla and sample sent for cytology. •There excellent spontaneous drainage of bile and contrast at the end of the procedure. •The pancreatic duct was partially filled with contrast and visualized proximally. •The course and caliber of the duct was irregular but no discrete filling defects were noted. Recommendations: •Admit to hospital for monitoring •NPO overnight with aggressive IV hydration with LR at 200 cc/hr •If no abdominal [MASKED] in the morning, advance diet to clear liquids and then advance as tolerated •No aspirin, Plavix, NSAIDS, Coumadin for 5 days. •Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days. •Follow up with cytology reports. Please call Dr. [MASKED] [MASKED] in 7 days for the pathology results. •Further recommendations based on cytology results. If cytology results are negative then will recommend EUS. •Follow for response and complications. If any abdominal [MASKED], fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call [MASKED] DISCHARGE LABS Brief Hospital Course: [MASKED] yo woman w/PMHx including chronic pancreatitis s/p distal pancreatectomy and Puestow with chronic abdominal [MASKED], now with ampullary stricture leading to severe CBD dilation, s/p [MASKED] ERCP with post procedure acute on chronic epigastric [MASKED] and hypoglycemia #Ampullary stricture/stenosis: #post ERCP acute on chronic pancreatitis: Leading to severe CBD dilation in the setting of chronic pancreatitis s/p distal pancreatectomy and Puestow. Now s/p ERCP with sphincterotomy. Procedure went well but she had acute post procedure [MASKED] consistent with acute on chronic pancreatitis. Per history, this was typical for her post ERCP and acute symptoms typically last several days. She was managed with supportive care and IV/PO analgesia with eventual improvement in her symptoms. She completed 5 days of Cipro. her bx was negative. She was discharged on her home methadone and a short course of oxycodone to taper over 5 days. PMP reviewed. She has a [MASKED] clinic appointment and was encouraged to follow up with Dr. [MASKED]. #Hypoglycemia/DM with neuropathy: Initially hypoglycemic in setting of NPO status and insulin administration to [MASKED]. Required D5 and D10. This was likely related to Lantus in the setting of her being NPO. Once she began eating her FSBG improved but maintained in the 100-low 200s. Thus, she was discharged OFF her lantus and ISS alone, pending follow up with her PCP. #Coagulopathy with h/o fatty liver disease: Improved slightly after dose of vitamin K - unclear etiology, suspect related to liver disease given mildly low albumin +/- nutritional component #Chronic abdominal [MASKED] - continue home methadone TID, use oxycodone for breakthrough [MASKED] post procedure on short term basis - [MASKED] clinic follow up arranged #COPD - used fluticasone-salmeterol here (don't have Symbicort on formulary), as well as PRN albuterol #Peptic ulcer disease, GERD - continued home PPI #Seizure disorder - lamotrigine, levetiracetam, topiramate #Legally blind Advance Care Planning: Health Care Proxy: will designate her husband, [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 200 mg PO DAILY 2. LevETIRAcetam 1500 mg PO BID 3. LamoTRIgine 400 mg PO QPM 4. Topiramate (Topamax) 100 mg PO BID 5. Omeprazole 40 mg PO DAILY 6. Gemfibrozil 600 mg PO BID 7. Glargine 55 Units Breakfast Glargine 55 Units Bedtime Insulin SC Sliding Scale using glulisine Insulin 8. Furosemide 40 mg PO DAILY:PRN swelling 9. Methadone 20 mg PO QAM 10. Methadone 15 mg PO BID 11. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY 12. Aspirin 81 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN [MASKED] - Moderate short term, PMP reviewed. taper as directed RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*13 Tablet Refills:*0 3. Senna 17.2 mg PO QHS 4. Insulin SC Sliding Scale Fingerstick QACHS, 3AM Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY 7. Furosemide 40 mg PO DAILY:PRN swelling 8. Gemfibrozil 600 mg PO BID 9. LamoTRIgine 200 mg PO DAILY 10. LamoTRIgine 400 mg PO QPM 11. LevETIRAcetam 1500 mg PO BID 12. Methadone 20 mg PO QAM 13. Methadone 15 mg PO BID 14. Omeprazole 40 mg PO DAILY 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing 16. Topiramate (Topamax) 100 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Chronic [MASKED] Dm2 COPD Sz disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for monitoring post ERCP. Post ERCP you developed acute abdominal [MASKED] which is now improving. your biopsy was negative. Please continue a low fat diet and stay well hydrated. Please follow up closely with your PCP, [MASKED]. [MASKED] the [MASKED] clinic. As we discussed, avoid alcohol and driving while taking oxycodone, and please taper as prescribed. Given your recent low blood sugars, you are being discharged OFF your lantus. Please check your blood glucose 4 times per day with sliding scale. Please follow up with your PCP regarding starting your Lantus. Followup Instructions: [MASKED]
[]
[ "G8929", "J449", "K219", "Z794", "Z87891" ]
[ "K8590: Acute pancreatitis without necrosis or infection, unspecified", "K831: Obstruction of bile duct", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "D684: Acquired coagulation factor deficiency", "K861: Other chronic pancreatitis", "K838: Other specified diseases of biliary tract", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "K760: Fatty (change of) liver, not elsewhere classified", "H548: Legal blindness, as defined in USA", "K219: Gastro-esophageal reflux disease without esophagitis", "R1013: Epigastric pain", "Z794: Long term (current) use of insulin", "Z8711: Personal history of peptic ulcer disease", "Z87891: Personal history of nicotine dependence" ]
10,062,317
21,352,614
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin / Penicillins / sertraline Attending: ___. Chief Complaint: L neck swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ with HTN, HLD, s/p L CEA for asymptomatic carotid stenosis at OSH presents with left neck swelling. She reports undergoing cardiac work-up in ___ in ___ for weakness. During this time she had a cardiac cath for which she was told was normal. She then underwent carotid ultrasound which she L sided stenosis (unclear the degree of stenosis). She denies ever having a stroke. She then came to the ___ in the wake of the hurricane and power outages. She then underwent pre-emptive left carotid endarterectomy on ___ with Dr. ___ at ___. Per her report she had swelling of the left neck prior to her surgery however the swelling persisted. This caused her to present to her PCP where she had a normal soft tissue ultrasound prompting a CT of the neck which found a possible carotid pseudoaneurysm vs. arterio-venous fistula for which she was transferred to ___ for further management. She denies any headaches, dizziness, visual changes, weakness, difficulty swallowing, chest pain, shortness of breath, abdominal pain, ___ pain, difficulty ambulating, changes in bowel or urinary habits Past Medical History: HTN, HLD, hypothyroidism, carotid stenosis s/p L CEA Social History: ___ Family History: non contributory Physical Exam: admission: 98.7 57 144/78 18 97%/RA GEN: A&Ox3, NAD HEENT: NCAT, EOMI, anicteric, CN2-12 intact, trachea midline, no palpable pulsatile mass, there is a swelling consistent with her pre-op swelling just above the clavicle which is soft and mobile and likely consistent with a lipoma CV: RRR PULM: no respiratory distress, unlabored respirations ABD: soft, non-distended, non-tender, no rebound or guarding EXT: WWP, no edema NEURO: A&Ox3, no focal neurologic deficits discharge: 98.5PO126 / 54 56 18 98%RA GEN: A&Ox3, NAD HEENT: NCAT, EOMI, anicteric, CN2-12 intact, trachea midline, no palpable pulsatile mass, there is a swelling consistent with her pre-op swelling just above the clavicle which is soft and mobile and likely consistent with a lipoma CV: RRR PULM: no respiratory distress, unlabored respirations ABD: soft, non-distended, non-tender, no rebound or guarding EXT: WWP, no edema NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: ___ 10:45PM BLOOD WBC-10.3* RBC-4.15 Hgb-11.2 Hct-34.3 MCV-83 MCH-27.0 MCHC-32.7 RDW-13.9 RDWSD-41.7 Plt ___ ___ 06:40AM BLOOD WBC-8.9 RBC-4.13 Hgb-11.0* Hct-34.9 MCV-85 MCH-26.6 MCHC-31.5* RDW-14.1 RDWSD-43.3 Plt ___ ___ 10:45PM BLOOD Neuts-53.2 ___ Monos-5.1 Eos-6.9 Baso-0.5 Im ___ AbsNeut-5.47 AbsLymp-3.51 AbsMono-0.52 AbsEos-0.71* AbsBaso-0.05 ___ 10:45PM BLOOD ___ PTT-25.6 ___ ___ 10:45PM BLOOD Plt ___ ___ 06:40AM BLOOD ___ PTT-23.9* ___ ___ 06:40AM BLOOD Plt ___ ___ 10:45PM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-143 K-3.3 Cl-103 HCO3-29 AnGap-11 ___ 06:40AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-145 K-3.9 Cl-105 HCO3-28 AnGap-12 Brief Hospital Course: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with acetaminophen. HEENT: A carotid duplex ultrasound demonstrated a c/f a neck mass with internal vascularity. A dedicated neck MRI and CTA of the neck corroborated these findings and the read showed a potential for a carotid body tumor, such as a paraganglioma. ENT was consulted. The ENT advised that there is no indication to operate at this time, and close monitoring of this mass should be done. As such, the patient will have follow up imaging in month's time and re-evaluation by both the vascular surgeon and ENT physician. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU/FEN: The patient was maintained on a regular diet. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. losartan-hydrochlorothiazide 50-12.5 mg oral ___ 2. amLODIPine 5 mg PO ___ 3. Clopidogrel 75 mg PO ___ 4. Simvastatin 10 mg PO QPM 5. Levothyroxine Sodium 25 mcg PO ___ 6. melatonin 3 mg oral QHS:PRN Discharge Medications: 1. amLODIPine 5 mg PO ___ 2. Clopidogrel 75 mg PO ___ 3. Levothyroxine Sodium 25 mcg PO ___ 4. losartan-hydrochlorothiazide 50-12.5 mg oral ___ 5. melatonin 3 mg oral QHS:PRN 6. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: vascular tumor of the parapharyngeal space Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were transferred to ___ after a CT scan at an outside hospital revealed a mass in your neck. The decision has been made that operating on this lesion is not indicated at this time. We would like to follow up with you in approximately 1 months time to further evaluate you. We have appointments scheduled for you to see both Dr. ___ vascular surgeon, and Dr. ___ otolaryngologist. Please contact us and let us know if anything changes in the interim. Thank you! Followup Instructions: ___
[ "D490", "Z7902", "Z98890", "I10", "E039", "E785" ]
Allergies: aspirin / Penicillins / sertraline Chief Complaint: L neck swelling Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with HTN, HLD, s/p L CEA for asymptomatic carotid stenosis at OSH presents with left neck swelling. She reports undergoing cardiac work-up in [MASKED] in [MASKED] for weakness. During this time she had a cardiac cath for which she was told was normal. She then underwent carotid ultrasound which she L sided stenosis (unclear the degree of stenosis). She denies ever having a stroke. She then came to the [MASKED] in the wake of the hurricane and power outages. She then underwent pre-emptive left carotid endarterectomy on [MASKED] with Dr. [MASKED] at [MASKED]. Per her report she had swelling of the left neck prior to her surgery however the swelling persisted. This caused her to present to her PCP where she had a normal soft tissue ultrasound prompting a CT of the neck which found a possible carotid pseudoaneurysm vs. arterio-venous fistula for which she was transferred to [MASKED] for further management. She denies any headaches, dizziness, visual changes, weakness, difficulty swallowing, chest pain, shortness of breath, abdominal pain, [MASKED] pain, difficulty ambulating, changes in bowel or urinary habits Past Medical History: HTN, HLD, hypothyroidism, carotid stenosis s/p L CEA Social History: [MASKED] Family History: non contributory Physical Exam: admission: 98.7 57 144/78 18 97%/RA GEN: A&Ox3, NAD HEENT: NCAT, EOMI, anicteric, CN2-12 intact, trachea midline, no palpable pulsatile mass, there is a swelling consistent with her pre-op swelling just above the clavicle which is soft and mobile and likely consistent with a lipoma CV: RRR PULM: no respiratory distress, unlabored respirations ABD: soft, non-distended, non-tender, no rebound or guarding EXT: WWP, no edema NEURO: A&Ox3, no focal neurologic deficits discharge: 98.5PO126 / 54 56 18 98%RA GEN: A&Ox3, NAD HEENT: NCAT, EOMI, anicteric, CN2-12 intact, trachea midline, no palpable pulsatile mass, there is a swelling consistent with her pre-op swelling just above the clavicle which is soft and mobile and likely consistent with a lipoma CV: RRR PULM: no respiratory distress, unlabored respirations ABD: soft, non-distended, non-tender, no rebound or guarding EXT: WWP, no edema NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: [MASKED] 10:45PM BLOOD WBC-10.3* RBC-4.15 Hgb-11.2 Hct-34.3 MCV-83 MCH-27.0 MCHC-32.7 RDW-13.9 RDWSD-41.7 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-8.9 RBC-4.13 Hgb-11.0* Hct-34.9 MCV-85 MCH-26.6 MCHC-31.5* RDW-14.1 RDWSD-43.3 Plt [MASKED] [MASKED] 10:45PM BLOOD Neuts-53.2 [MASKED] Monos-5.1 Eos-6.9 Baso-0.5 Im [MASKED] AbsNeut-5.47 AbsLymp-3.51 AbsMono-0.52 AbsEos-0.71* AbsBaso-0.05 [MASKED] 10:45PM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 10:45PM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD [MASKED] PTT-23.9* [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 10:45PM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-143 K-3.3 Cl-103 HCO3-29 AnGap-11 [MASKED] 06:40AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-145 K-3.9 Cl-105 HCO3-28 AnGap-12 Brief Hospital Course: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with acetaminophen. HEENT: A carotid duplex ultrasound demonstrated a c/f a neck mass with internal vascularity. A dedicated neck MRI and CTA of the neck corroborated these findings and the read showed a potential for a carotid body tumor, such as a paraganglioma. ENT was consulted. The ENT advised that there is no indication to operate at this time, and close monitoring of this mass should be done. As such, the patient will have follow up imaging in month's time and re-evaluation by both the vascular surgeon and ENT physician. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU/FEN: The patient was maintained on a regular diet. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. losartan-hydrochlorothiazide 50-12.5 mg oral [MASKED] 2. amLODIPine 5 mg PO [MASKED] 3. Clopidogrel 75 mg PO [MASKED] 4. Simvastatin 10 mg PO QPM 5. Levothyroxine Sodium 25 mcg PO [MASKED] 6. melatonin 3 mg oral QHS:PRN Discharge Medications: 1. amLODIPine 5 mg PO [MASKED] 2. Clopidogrel 75 mg PO [MASKED] 3. Levothyroxine Sodium 25 mcg PO [MASKED] 4. losartan-hydrochlorothiazide 50-12.5 mg oral [MASKED] 5. melatonin 3 mg oral QHS:PRN 6. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: vascular tumor of the parapharyngeal space Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were transferred to [MASKED] after a CT scan at an outside hospital revealed a mass in your neck. The decision has been made that operating on this lesion is not indicated at this time. We would like to follow up with you in approximately 1 months time to further evaluate you. We have appointments scheduled for you to see both Dr. [MASKED] vascular surgeon, and Dr. [MASKED] otolaryngologist. Please contact us and let us know if anything changes in the interim. Thank you! Followup Instructions: [MASKED]
[]
[ "Z7902", "I10", "E039", "E785" ]
[ "D490: Neoplasm of unspecified behavior of digestive system", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z98890: Other specified postprocedural states", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified" ]
10,062,317
28,671,054
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin / Penicillins / sertraline Attending: ___. Chief Complaint: Left neck mass medial to the carotid artery. Major Surgical or Invasive Procedure: Radical left neck exploration with lymph node sampling of stations one through four, resection of vascular lesion from the parapharyngeal space medial to the left carotid, and excision of subcutaneous lipoma. History of Present Illness: Ms. ___ is a ___ female who had a left carotid endarterectomy for asymptomatic carotid stenosis at an outside hospital. She reported with incidental finding of a prestyloid lesion. She reported undergoing cardiac workup in ___ for weakness and then ultimately had this carotid endarterectomy. The patient complained of a left-sided neck mass which was soft tissue and a CT scan was done which showed a possible carotid pseudoaneurysm versus AV fistula in the left parapharyngeal space and for which she was referred to ___ ___. Past Medical History: HTN, HLD, hypothyroidism, carotid stenosis s/p L CEA Social History: ___ Family History: non contributory Physical Exam: Discharge Physical Exam Vitals: 98.2 119/71 63 18 99%RA General: Well appearing, non cachectic ___: RRR Pulm: no respiratory distress, no crackles Abdomen: Soft, NT, ND, Incision: clean/dry/intact with steri strips Brief Hospital Course: Ms. ___ is a ___ year old Female with a Left-sided carotid mass in the Left parapharyngeal space who was admitted to the ___ ___ on ___. The patient was taken to the operating room and underwent a radical left neck exploration with lymph node sampling and resection of her parapharyngeal lesion. A 10-mm flat ___ drain was placed in the left neck and closed. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization. On postoperative check her drain appeared sanguinous, expected from her immediate recent surgery. She was hemodynamically stable and was placed on a regular diet. On POD1 her neck drain had a more serosanguinous consistency. The patient was complaining of trouble swallowing and a feeling of food getting stuck in her throat. She was exclusively eating jello given extreme discomfort with solid foot. She did not complain of trouble with liquids. The patient was otherwise neurologically intact and there were no concerns of aspiration. She just had discomfort on swallowing. Occupational therapy evaluated the patient for shoulder motion given her neck surgery and possibly expected postoperative shoulder pain. OT recommended home with no acute occupational therapy needs. Hence, order for OT was removed. On the evening of POD1, a cranial nerve exam was performed and it was noted that the patient had an irregular smile with inferior left facial droop and mild ptosis on the left side, both on same side of her surgery. That same evening a code stroke was activated given the new onset of neurologic symptoms on exam and her surgery near Left carotid artery. Neurology immediately came to assess her and code stroke was activated. At time of arrival patients SBP 115, BG 124 and NIHSS 2 for partial left facial droop with NLFF. Patients reported she was feeling well without weakness, numbness, tingling, dysarthria, difficulty speaking, double vision. She had noted a left sided headache since her procedure with some difficulty swallowing, feeling like food was getting stuck in her throat (but she was intubated for the procedure). Thirty minutes after code stroke, the left nasolabial fold flattening and droop had resolved and there was just subtle less prominent nasolabial fold flattening on the right without asymmetry. ___ showed no hemorrhage or large territory infarction or signs of ischemia. CTA showed some atherosclerosis, right ICA stenosis (appearing <50% but final read pending) but no large vessel cut off. There were also post surgical changes in the neck. Recommendations were to trend q4h neuro exam and page if acute change, with consideration of MRI if exam did not improve or worsened. Her facial drooping partially resolved throughout the course of her hospitalization and neuro exam remained otherwise intact throughout. On POD2 the patient was still complaining of her difficulty with swallowing. The speech and swallow team was consulted and it was clarified to them that the patient only needed swallowing exercises and we were not concerned of a risk for aspiration. Swallow team evaluated the patient and recommended thin liquid and regular solid diet, self-selecting softer foods as needed secondary to pain. They suggested the patient to consider a left head turn, as if there is swelling in the L pharynx, this would divert the bolus to the unaffected right side. On POD3 neurology assessed the patient and signed off afterwards. The patient started having gum pain. Gabapentin was given 300mg TID which partially controlled her pain. Her drain output was serosanguinous with decreased output compared to previous day. On POD4 the patient continued to complain of pain in her gums, thus, it was decided to keep her one more day in the hospital for pain control before discharge. On POD5,she was doing well with well controlled pain. Her swallowing had improved although with residual discomfort however said she was instructed to continue following the recommendations from the swallow team. 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. She was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: Losartin-HCTZ 50-12.5', amlodipine 5mg', Plavix 75mg', simvastatin 10mg' (clarify), levothyroxine 25mcg', melatonin prn Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 160 mg/5 mL 10 mL by mouth every six (6) hours Disp #*250 Milliliter Refills:*0 2. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 (One) capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *hydromorphone [Dilaudid] 2 mg 1 (One) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 4. Atorvastatin 40 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. LORazepam 0.5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Left neck mass status post radical left neck exploration with lymph node sampling and resection of vascular lesion from the parapharyngeal space. 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 ___ and underwent a Left-sided parapharyngeal tumor resection (mass located in your neck). You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: WHAT TO EXPECT: 1. Surgical Incision: • It is normal to have some swelling and feel a firm ridge along the incision • Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness • Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery • Try ibuprofen, acetaminophen, or your discharge pain medication • If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon’s office 4. It is normal to feel tired, this will last for ___ weeks • You should get up out of bed every day and gradually increase your activity each day • You may walk and you may go up and down stairs • Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time • You will probably lose your taste for food and lose some weight • Eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: • Take all of your medications as prescribed in your discharge ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit • You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area CALL THE OFFICE FOR: ___ • Changes in vision (loss of vision, blurring, double vision, half vision) • Slurring of speech or difficulty finding correct words to use • Severe headache or worsening headache not controlled by pain medication • A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg • Trouble swallowing, breathing, or talking • Temperature greater than 101.5F for 24 hours • Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: ___
[ "D492", "G9782", "D170", "I10", "E785", "E039", "Z7902", "Z87891", "R29810", "R1310", "I6521", "Y838", "Y92230" ]
Allergies: aspirin / Penicillins / sertraline Chief Complaint: Left neck mass medial to the carotid artery. Major Surgical or Invasive Procedure: Radical left neck exploration with lymph node sampling of stations one through four, resection of vascular lesion from the parapharyngeal space medial to the left carotid, and excision of subcutaneous lipoma. History of Present Illness: Ms. [MASKED] is a [MASKED] female who had a left carotid endarterectomy for asymptomatic carotid stenosis at an outside hospital. She reported with incidental finding of a prestyloid lesion. She reported undergoing cardiac workup in [MASKED] for weakness and then ultimately had this carotid endarterectomy. The patient complained of a left-sided neck mass which was soft tissue and a CT scan was done which showed a possible carotid pseudoaneurysm versus AV fistula in the left parapharyngeal space and for which she was referred to [MASKED] [MASKED]. Past Medical History: HTN, HLD, hypothyroidism, carotid stenosis s/p L CEA Social History: [MASKED] Family History: non contributory Physical Exam: Discharge Physical Exam Vitals: 98.2 119/71 63 18 99%RA General: Well appearing, non cachectic [MASKED]: RRR Pulm: no respiratory distress, no crackles Abdomen: Soft, NT, ND, Incision: clean/dry/intact with steri strips Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old Female with a Left-sided carotid mass in the Left parapharyngeal space who was admitted to the [MASKED] [MASKED] on [MASKED]. The patient was taken to the operating room and underwent a radical left neck exploration with lymph node sampling and resection of her parapharyngeal lesion. A 10-mm flat [MASKED] drain was placed in the left neck and closed. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization. On postoperative check her drain appeared sanguinous, expected from her immediate recent surgery. She was hemodynamically stable and was placed on a regular diet. On POD1 her neck drain had a more serosanguinous consistency. The patient was complaining of trouble swallowing and a feeling of food getting stuck in her throat. She was exclusively eating jello given extreme discomfort with solid foot. She did not complain of trouble with liquids. The patient was otherwise neurologically intact and there were no concerns of aspiration. She just had discomfort on swallowing. Occupational therapy evaluated the patient for shoulder motion given her neck surgery and possibly expected postoperative shoulder pain. OT recommended home with no acute occupational therapy needs. Hence, order for OT was removed. On the evening of POD1, a cranial nerve exam was performed and it was noted that the patient had an irregular smile with inferior left facial droop and mild ptosis on the left side, both on same side of her surgery. That same evening a code stroke was activated given the new onset of neurologic symptoms on exam and her surgery near Left carotid artery. Neurology immediately came to assess her and code stroke was activated. At time of arrival patients SBP 115, BG 124 and NIHSS 2 for partial left facial droop with NLFF. Patients reported she was feeling well without weakness, numbness, tingling, dysarthria, difficulty speaking, double vision. She had noted a left sided headache since her procedure with some difficulty swallowing, feeling like food was getting stuck in her throat (but she was intubated for the procedure). Thirty minutes after code stroke, the left nasolabial fold flattening and droop had resolved and there was just subtle less prominent nasolabial fold flattening on the right without asymmetry. [MASKED] showed no hemorrhage or large territory infarction or signs of ischemia. CTA showed some atherosclerosis, right ICA stenosis (appearing <50% but final read pending) but no large vessel cut off. There were also post surgical changes in the neck. Recommendations were to trend q4h neuro exam and page if acute change, with consideration of MRI if exam did not improve or worsened. Her facial drooping partially resolved throughout the course of her hospitalization and neuro exam remained otherwise intact throughout. On POD2 the patient was still complaining of her difficulty with swallowing. The speech and swallow team was consulted and it was clarified to them that the patient only needed swallowing exercises and we were not concerned of a risk for aspiration. Swallow team evaluated the patient and recommended thin liquid and regular solid diet, self-selecting softer foods as needed secondary to pain. They suggested the patient to consider a left head turn, as if there is swelling in the L pharynx, this would divert the bolus to the unaffected right side. On POD3 neurology assessed the patient and signed off afterwards. The patient started having gum pain. Gabapentin was given 300mg TID which partially controlled her pain. Her drain output was serosanguinous with decreased output compared to previous day. On POD4 the patient continued to complain of pain in her gums, thus, it was decided to keep her one more day in the hospital for pain control before discharge. On POD5,she was doing well with well controlled pain. Her swallowing had improved although with residual discomfort however said she was instructed to continue following the recommendations from the swallow team. 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. She was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: Losartin-HCTZ 50-12.5', amlodipine 5mg', Plavix 75mg', simvastatin 10mg' (clarify), levothyroxine 25mcg', melatonin prn Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 160 mg/5 mL 10 mL by mouth every six (6) hours Disp #*250 Milliliter Refills:*0 2. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 (One) capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *hydromorphone [Dilaudid] 2 mg 1 (One) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 4. Atorvastatin 40 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. LORazepam 0.5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Left neck mass status post radical left neck exploration with lymph node sampling and resection of vascular lesion from the parapharyngeal space. 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] and underwent a Left-sided parapharyngeal tumor resection (mass located in your neck). You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: WHAT TO EXPECT: 1. Surgical Incision: • It is normal to have some swelling and feel a firm ridge along the incision • Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness • Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery • Try ibuprofen, acetaminophen, or your discharge pain medication • If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon’s office 4. It is normal to feel tired, this will last for [MASKED] weeks • You should get up out of bed every day and gradually increase your activity each day • You may walk and you may go up and down stairs • Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time • You will probably lose your taste for food and lose some weight • Eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: • Take all of your medications as prescribed in your discharge ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit • You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area CALL THE OFFICE FOR: [MASKED] • Changes in vision (loss of vision, blurring, double vision, half vision) • Slurring of speech or difficulty finding correct words to use • Severe headache or worsening headache not controlled by pain medication • A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg • Trouble swallowing, breathing, or talking • Temperature greater than 101.5F for 24 hours • Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: [MASKED]
[]
[ "I10", "E785", "E039", "Z7902", "Z87891", "Y92230" ]
[ "D492: Neoplasm of unspecified behavior of bone, soft tissue, and skin", "G9782: Other postprocedural complications and disorders of nervous system", "D170: Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z87891: Personal history of nicotine dependence", "R29810: Facial weakness", "R1310: Dysphagia, unspecified", "I6521: Occlusion and stenosis of right carotid artery", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,062,399
25,465,262
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right arm pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ male with HTN, BPH who presents with worsening right forearm pain that began approximately three hours after using a electric jackhammer for 30 minutes (pain started at 1500). He felt normal after using the jackhammer, however then developed some fore arm pain and numbness in his right radial distribution, along with forearm tightness. He presented to ___ and was transferred here for orthopedic evaluation and rule out compartment syndrome. The patient describes difficulty on extension of his fingers and adduction of fingers, but no weakness. Patient denies any other injuries. Patient denies any recent trauma, or arthropod bites. Patient seen at ___ prior to arrival with x-rays notable for no significant fracture or dislocation. Patient denies fevers, chills, sweats. Denies IVDU. In the ED, initial VS were: 97.9 68 125/82 16 94% RA Exam notable for: Right forearm with notable tension and swelling of the mobile wad and dorsal compartment of the right forearm, soft volar forearm compartment, erythema or induration of the dorsal compartment extending to the dorsum of the hand. Patient with difficulty on extension of the MCP joint and adduction of the fingers. Labs showed: WBC 11.1, Hgb 12.3, Plt 173, CK 6422, BUN 26, Cr 2.3, lactate 1.4, UA mod blood, 5 WBC, < 1RBC, Protein 30, 10 ketones, few bacteria, negative leuk, neg nitrite. Imaging showed: Diffuse subcutaneous edema in the right proximal forearm. No focal hematoma or fluid collection. Patient received: ___ 20:21 IV Ondansetron 4 mg ___ ___ 20:21 IVF NS ( 1000 mL ordered) ___ Started Stop ___ 20:21 IV HYDROmorphone (Dilaudid) .5 mg ___ ___ ___ 20:23 PO Acetaminophen 1000 mg ___ ___ 23:00 IV HYDROmorphone (Dilaudid) .5 mg ___ ___ Hand surgery was consulted: ___ pressures checked by fellow. Mobile wad 19, extensor 21. Low concern for compartment syndrome. No operative intervention at this time. ___ to continue with elevation Transfer VS were: 98.5 68 142/55 19 96% RA On arrival to the floor, patient endorses above. Still having pain. IV Dilaudid 0.5mg improved pain slightly, but pain still ___. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: HTN BPH Social History: ___ Family History: Denies any kidney disease. Father died of old age. Mother died of PNA in her ___ after an ulcer surgery. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.3 179 / 74 83 20 95% RA GENERAL: NAD, very pleasant HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No edema RIGHT ARM: Edematous, firm right forearm compared to left. Non tender to palpation. Thin erosion over dorsal aspect of forearm, reportedly from tape tear. 2+ radial pulse. Difficulty extending all digits. intact sensation in all digits. 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: 99.1 177/72 66 18 96 RA GENERAL: NAD, pleasant HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No edema RIGHT ARM: Elevated with dressing in place with ice packs, edematous. R arm less erythematous. right forearm in sling upright. Non tender to palpation. Thin erosion over dorsal aspect of forearm, as well as blisters. 2+ radial pulse. Difficulty extending all digits. intact sensation in all digits. 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 ============== ___ 07:51PM BLOOD WBC-11.1* RBC-4.24* Hgb-12.3* Hct-37.9* MCV-89 MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.5 Plt ___ ___ 07:51PM BLOOD Neuts-84.3* Lymphs-9.9* Monos-5.2 Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.39* AbsLymp-1.10* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.02 ___ 07:51PM BLOOD ___ PTT-26.4 ___ ___ 07:51PM BLOOD Glucose-103* UreaN-26* Creat-2.3* Na-142 K-4.4 Cl-104 HCO3-23 AnGap-15 ___ 07:51PM BLOOD CK(CPK)-6422* ___ 07:51PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0 Discharge labs ============== ___ 05:15AM BLOOD WBC-11.7* RBC-4.30* Hgb-12.6* Hct-38.4* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.6 RDWSD-44.4 Plt ___ ___ 05:15AM BLOOD Glucose-88 UreaN-23* Creat-1.8* Na-139 K-4.6 Cl-102 HCO3-24 AnGap-13 ___ 05:15AM BLOOD ALT-32 AST-124* LD(LDH)-327* CK(CPK)-2186* AlkPhos-136* TotBili-0.5 ___ 05:15AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9 Micro ===== ___ 11:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Imaging ======= US upper extremity ___ Diffuse subcutaneous edema in the right proximal forearm including in the musculature. No focal hematoma or fluid collection. RUE US ___ No evidence of deep vein thrombosis in the right upper extremity. Soft tissue edema. Brief Hospital Course: BRIEF HOSPITAL COURSE ===================== ___ male with HTN, BPH who presents with right forearm pain, swelling, after using electric jackhammer, with concern for compartment syndrome, found to have rhabdomyolysis with CK 6422 and Cr 2.3 (baseline 2.0). Patient was seen by hand surgery team and ruled out for compartment syndrome due to reassuring pressures inside arm. His CK improved with hydration and Cr stayed at baseline. He was also treated with Kelfex for L arm cellulitis due to skin breakdown and was discharged on a 7 day course of Keflex with close followup with ortho and his PCP. ACTIVE PROBLEMS =============== # R arm soft tissue injury # Elevated CK # Rhabdomyolysis Patient used jackhammer x 30 min and then developed sudden right arm swelling, tension, pain. Patient with right forearm pain and swelling that brought initial concern for compartment syndrome concerning for possible compartment syndrome but orthopedics hand following and not concerned for compartment syndrome, but more for exertional type muscular injury w/ significant soft tissue swelling. Started on Kelfex for possible cellulitis of R upper arm, and seemed to have improved in terms of erythema and swelling. Right arm ultrasound was negative for DVT. Was seen by occupational therapy who recommended wrist cockup splint. #Chronic kidney disease - baseline Cr ~2.2. UA Moderate blood but < 1RBCs, CK of 6400, and Cr 2.3 suggestive of rhabdomyolysis. Baseline Cr is 2.1 as far as ___. Initially received fluids and CK started downtrending. CK at discharge was 2186. Lisinopril was initially held since we are not sure about his baseline Cr, but once we confirmed it with his nephrologist and found out he is at baseline we continued home lisinopril 5mg daily. Creatinine improved to 1.8 at discharge. CHRONIC ============== # BPH - Continued home tamsulosin 0.4 mg QHS # Back pain - Continued home gabapentin 100mg TID (renally dosed) # Primary prevention - continued home ASA 81mg TRANSITIONAL ISSUES: - New Meds: Cephalexin 500 mg PO/NG Q8H for a 7 day course until ___ - Stopped/Held Meds: none - Changed Meds: none - Please re-assess right arm on follow-up visit and decide if the 7 day course until ___ is enough or if he needs 7 additional days - Patient needs to followup with orthopedic surgery post discharge on ___. The ortho team will call the patient on ___ to setup this appointment. If this will not happen, the patient will need to call ___ to schedule at appointment. - Patient needs to continue daily changes to his right hand, keep it elevated at all possible tines and do dressing changes with Silver Sulfadiazine 1%, Adaptic, Dry gauze and Kerlex. # CODE: Full code # CONTACT: ___ Relationship: son Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Gabapentin 100 mg PO TID 4. Aspirin 81 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO Q8H RX *cephalexin 500 mg 1 capsule(s) by mouth Q8Hrs Disp #*18 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. Gabapentin 100 mg PO TID 4. Lisinopril 5 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7.Outpatient Occupational Therapy ICD-10 Code: ___.___ Diagnosis: R hand stiffness Occupational therapy for right hand/fingers Strength, ROM, RUE HEP. Also ADL's Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Right arm soft tissue injury Rhabodmyolysis Chronic kidney disease Secondary diagnosis: Benign prostate hyperplasia Back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure caring for you at ___ ___! WHY WERE YOU ADMITTED? You were admitted for swelling and pain in your right arm after using a jackhammer. WHAT HAPPENED IN THE HOSPITAL? You were seen by our colleagues from hand surgery who did not think you had "compartment syndrome" - increased pressure within your arm. Your arm was placed in a sling, kept elevated, and dressing was placed on. You were treated for your skin breakdown. Also, you received a short course of antibiotics for possible skin infection which you need to continue after you leave the hospital. WHAT SHOULD YOU DO AT HOME? You need to continue to hold your arm elevated at all possible times. You need to continue with dressing changes daily with the help of a ___ we will setup for you. You need to follow up with hand surgery on ___ and with your PCP on ___ You need to continue taking antibiotics until ___. The orthopedics team will contact you tomorrow ___ to schedule the appointment on ___. If that does not happen please call ___ to schedule an appointment with Dr ___. Thank you for allowing us be involved in your care, we wish you all the best! Your ___ Team Followup Instructions: ___
[ "T796XXA", "L03113", "I129", "N400", "N189", "Y92009", "W311XXA", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right arm pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] male with HTN, BPH who presents with worsening right forearm pain that began approximately three hours after using a electric jackhammer for 30 minutes (pain started at 1500). He felt normal after using the jackhammer, however then developed some fore arm pain and numbness in his right radial distribution, along with forearm tightness. He presented to [MASKED] and was transferred here for orthopedic evaluation and rule out compartment syndrome. The patient describes difficulty on extension of his fingers and adduction of fingers, but no weakness. Patient denies any other injuries. Patient denies any recent trauma, or arthropod bites. Patient seen at [MASKED] prior to arrival with x-rays notable for no significant fracture or dislocation. Patient denies fevers, chills, sweats. Denies IVDU. In the ED, initial VS were: 97.9 68 125/82 16 94% RA Exam notable for: Right forearm with notable tension and swelling of the mobile wad and dorsal compartment of the right forearm, soft volar forearm compartment, erythema or induration of the dorsal compartment extending to the dorsum of the hand. Patient with difficulty on extension of the MCP joint and adduction of the fingers. Labs showed: WBC 11.1, Hgb 12.3, Plt 173, CK 6422, BUN 26, Cr 2.3, lactate 1.4, UA mod blood, 5 WBC, < 1RBC, Protein 30, 10 ketones, few bacteria, negative leuk, neg nitrite. Imaging showed: Diffuse subcutaneous edema in the right proximal forearm. No focal hematoma or fluid collection. Patient received: [MASKED] 20:21 IV Ondansetron 4 mg [MASKED] [MASKED] 20:21 IVF NS ( 1000 mL ordered) [MASKED] Started Stop [MASKED] 20:21 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] [MASKED] [MASKED] 20:23 PO Acetaminophen 1000 mg [MASKED] [MASKED] 23:00 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] [MASKED] Hand surgery was consulted: [MASKED] pressures checked by fellow. Mobile wad 19, extensor 21. Low concern for compartment syndrome. No operative intervention at this time. [MASKED] to continue with elevation Transfer VS were: 98.5 68 142/55 19 96% RA On arrival to the floor, patient endorses above. Still having pain. IV Dilaudid 0.5mg improved pain slightly, but pain still [MASKED]. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: HTN BPH Social History: [MASKED] Family History: Denies any kidney disease. Father died of old age. Mother died of PNA in her [MASKED] after an ulcer surgery. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.3 179 / 74 83 20 95% RA GENERAL: NAD, very pleasant HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No edema RIGHT ARM: Edematous, firm right forearm compared to left. Non tender to palpation. Thin erosion over dorsal aspect of forearm, reportedly from tape tear. 2+ radial pulse. Difficulty extending all digits. intact sensation in all digits. 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: 99.1 177/72 66 18 96 RA GENERAL: NAD, pleasant HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No edema RIGHT ARM: Elevated with dressing in place with ice packs, edematous. R arm less erythematous. right forearm in sling upright. Non tender to palpation. Thin erosion over dorsal aspect of forearm, as well as blisters. 2+ radial pulse. Difficulty extending all digits. intact sensation in all digits. 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] 07:51PM BLOOD WBC-11.1* RBC-4.24* Hgb-12.3* Hct-37.9* MCV-89 MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.5 Plt [MASKED] [MASKED] 07:51PM BLOOD Neuts-84.3* Lymphs-9.9* Monos-5.2 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-9.39* AbsLymp-1.10* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.02 [MASKED] 07:51PM BLOOD [MASKED] PTT-26.4 [MASKED] [MASKED] 07:51PM BLOOD Glucose-103* UreaN-26* Creat-2.3* Na-142 K-4.4 Cl-104 HCO3-23 AnGap-15 [MASKED] 07:51PM BLOOD CK(CPK)-6422* [MASKED] 07:51PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0 Discharge labs ============== [MASKED] 05:15AM BLOOD WBC-11.7* RBC-4.30* Hgb-12.6* Hct-38.4* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.6 RDWSD-44.4 Plt [MASKED] [MASKED] 05:15AM BLOOD Glucose-88 UreaN-23* Creat-1.8* Na-139 K-4.6 Cl-102 HCO3-24 AnGap-13 [MASKED] 05:15AM BLOOD ALT-32 AST-124* LD(LDH)-327* CK(CPK)-2186* AlkPhos-136* TotBili-0.5 [MASKED] 05:15AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9 Micro ===== [MASKED] 11:00 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. Imaging ======= US upper extremity [MASKED] Diffuse subcutaneous edema in the right proximal forearm including in the musculature. No focal hematoma or fluid collection. RUE US [MASKED] No evidence of deep vein thrombosis in the right upper extremity. Soft tissue edema. Brief Hospital Course: BRIEF HOSPITAL COURSE ===================== [MASKED] male with HTN, BPH who presents with right forearm pain, swelling, after using electric jackhammer, with concern for compartment syndrome, found to have rhabdomyolysis with CK 6422 and Cr 2.3 (baseline 2.0). Patient was seen by hand surgery team and ruled out for compartment syndrome due to reassuring pressures inside arm. His CK improved with hydration and Cr stayed at baseline. He was also treated with Kelfex for L arm cellulitis due to skin breakdown and was discharged on a 7 day course of Keflex with close followup with ortho and his PCP. ACTIVE PROBLEMS =============== # R arm soft tissue injury # Elevated CK # Rhabdomyolysis Patient used jackhammer x 30 min and then developed sudden right arm swelling, tension, pain. Patient with right forearm pain and swelling that brought initial concern for compartment syndrome concerning for possible compartment syndrome but orthopedics hand following and not concerned for compartment syndrome, but more for exertional type muscular injury w/ significant soft tissue swelling. Started on Kelfex for possible cellulitis of R upper arm, and seemed to have improved in terms of erythema and swelling. Right arm ultrasound was negative for DVT. Was seen by occupational therapy who recommended wrist cockup splint. #Chronic kidney disease - baseline Cr ~2.2. UA Moderate blood but < 1RBCs, CK of 6400, and Cr 2.3 suggestive of rhabdomyolysis. Baseline Cr is 2.1 as far as [MASKED]. Initially received fluids and CK started downtrending. CK at discharge was 2186. Lisinopril was initially held since we are not sure about his baseline Cr, but once we confirmed it with his nephrologist and found out he is at baseline we continued home lisinopril 5mg daily. Creatinine improved to 1.8 at discharge. CHRONIC ============== # BPH - Continued home tamsulosin 0.4 mg QHS # Back pain - Continued home gabapentin 100mg TID (renally dosed) # Primary prevention - continued home ASA 81mg TRANSITIONAL ISSUES: - New Meds: Cephalexin 500 mg PO/NG Q8H for a 7 day course until [MASKED] - Stopped/Held Meds: none - Changed Meds: none - Please re-assess right arm on follow-up visit and decide if the 7 day course until [MASKED] is enough or if he needs 7 additional days - Patient needs to followup with orthopedic surgery post discharge on [MASKED]. The ortho team will call the patient on [MASKED] to setup this appointment. If this will not happen, the patient will need to call [MASKED] to schedule at appointment. - Patient needs to continue daily changes to his right hand, keep it elevated at all possible tines and do dressing changes with Silver Sulfadiazine 1%, Adaptic, Dry gauze and Kerlex. # CODE: Full code # CONTACT: [MASKED] Relationship: son Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Gabapentin 100 mg PO TID 4. Aspirin 81 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO Q8H RX *cephalexin 500 mg 1 capsule(s) by mouth Q8Hrs Disp #*18 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. Gabapentin 100 mg PO TID 4. Lisinopril 5 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7.Outpatient Occupational Therapy ICD-10 Code: [MASKED].[MASKED] Diagnosis: R hand stiffness Occupational therapy for right hand/fingers Strength, ROM, RUE HEP. Also ADL's Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Right arm soft tissue injury Rhabodmyolysis Chronic kidney disease Secondary diagnosis: Benign prostate hyperplasia Back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]! WHY WERE YOU ADMITTED? You were admitted for swelling and pain in your right arm after using a jackhammer. WHAT HAPPENED IN THE HOSPITAL? You were seen by our colleagues from hand surgery who did not think you had "compartment syndrome" - increased pressure within your arm. Your arm was placed in a sling, kept elevated, and dressing was placed on. You were treated for your skin breakdown. Also, you received a short course of antibiotics for possible skin infection which you need to continue after you leave the hospital. WHAT SHOULD YOU DO AT HOME? You need to continue to hold your arm elevated at all possible times. You need to continue with dressing changes daily with the help of a [MASKED] we will setup for you. You need to follow up with hand surgery on [MASKED] and with your PCP on [MASKED] You need to continue taking antibiotics until [MASKED]. The orthopedics team will contact you tomorrow [MASKED] to schedule the appointment on [MASKED]. If that does not happen please call [MASKED] to schedule an appointment with Dr [MASKED]. Thank you for allowing us be involved in your care, we wish you all the best! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I129", "N400", "N189", "Z87891" ]
[ "T796XXA: Traumatic ischemia of muscle, initial encounter", "L03113: Cellulitis of right upper limb", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "N189: Chronic kidney disease, unspecified", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "W311XXA: Contact with metalworking machines, initial encounter", "Z87891: Personal history of nicotine dependence" ]
10,062,411
27,283,803
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: post polypectomy bleeding, BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o with no sig med hx documented or reported who has polypectomy (rectal polyp) here ___, and who developed large brbpr once yesterday, referred to the ED by GI yest. HD stable, no anemia, bleeding not persisting, asymptomatic at current. Seen in ED, no intervention other than tap water enema for planned flex sig. Admitted Past Medical History: OA rt wrist Pt. endorses sig etoh use on my exam - nightly large bottle of wine and several beers - likely 10+ servings of etoh NIGHTLY for ___ years. Denies w/d, seizure in past, but only stopped once for a few weeks several years ago, has had nightly etoh since. Endorses desire to quit, guilt about drinking, and interference with his work, on a family history of alcoholism. Social History: ___ Family History: Mother was alcoholic. Otherwise denies sig history Physical Exam: AF and VSS NAD Fully alert, oriented Slight smell of ethanol evident Slightly sweaty, but denies pain/anxiety No tremors MMM RRR no mrg CTA throughout Abd s/nt/nd/bs present, no hsm No edema Rt wrist with visible prior fracture (old/nt) and OA No rash Moves all ext Speech fluent and strength full and symmetric in extremities Pertinent Results: See omr Brief Hospital Course: Impression: 1 Lower GI bleeding, Bright red. No hemodynamic instability, Hct normal. Went for flex sig, addnl clip placed, epinephrine injected. No bleeding evident during observation overnight following, am hct still normal. No complaints, felt well clinically throughout hospitalization 2. Likely alcoholism No evidence of w/d. SW visited with pt. and provided resources for assistance in cutting back (what pt wants to) and quitting etoh use (what was advocated) Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: post polypectomy rectal bleeding, abated Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: see below; If you need something for constipation, both miralax and docusate sodium are available over the counter - use as instructed on the packaging Followup Instructions: ___
[ "K91840", "F1020", "Y838", "Y929", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: post polypectomy bleeding, BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] y/o with no sig med hx documented or reported who has polypectomy (rectal polyp) here [MASKED], and who developed large brbpr once yesterday, referred to the ED by GI yest. HD stable, no anemia, bleeding not persisting, asymptomatic at current. Seen in ED, no intervention other than tap water enema for planned flex sig. Admitted Past Medical History: OA rt wrist Pt. endorses sig etoh use on my exam - nightly large bottle of wine and several beers - likely 10+ servings of etoh NIGHTLY for [MASKED] years. Denies w/d, seizure in past, but only stopped once for a few weeks several years ago, has had nightly etoh since. Endorses desire to quit, guilt about drinking, and interference with his work, on a family history of alcoholism. Social History: [MASKED] Family History: Mother was alcoholic. Otherwise denies sig history Physical Exam: AF and VSS NAD Fully alert, oriented Slight smell of ethanol evident Slightly sweaty, but denies pain/anxiety No tremors MMM RRR no mrg CTA throughout Abd s/nt/nd/bs present, no hsm No edema Rt wrist with visible prior fracture (old/nt) and OA No rash Moves all ext Speech fluent and strength full and symmetric in extremities Pertinent Results: See omr Brief Hospital Course: Impression: 1 Lower GI bleeding, Bright red. No hemodynamic instability, Hct normal. Went for flex sig, addnl clip placed, epinephrine injected. No bleeding evident during observation overnight following, am hct still normal. No complaints, felt well clinically throughout hospitalization 2. Likely alcoholism No evidence of w/d. SW visited with pt. and provided resources for assistance in cutting back (what pt wants to) and quitting etoh use (what was advocated) Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: post polypectomy rectal bleeding, abated Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: see below; If you need something for constipation, both miralax and docusate sodium are available over the counter - use as instructed on the packaging Followup Instructions: [MASKED]
[]
[ "Y929", "Z87891" ]
[ "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "F1020: Alcohol dependence, uncomplicated", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence" ]
10,062,411
28,810,918
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left-sided medial knee pain Major Surgical or Invasive Procedure: left partial knee replacement ___, ___ History of Present Illness: ___ male with ongoing left-sided medial specific knee pain. This is been refractory to conservative therapy. Unable to tolerate NSAIDs due to gastric irritation, patient presents for left medial unicompartmental arthroplasty. Past Medical History: Shoulder pain, OA right wrist, anxiety disorder, sciatica, migraines, alcohol use disorder 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 no serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 07:30AM BLOOD Hgb-12.4* Hct-37.6* ___ 07:30AM BLOOD Creat-0.8 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: Overnight POD#0, the patient was hypertensive to 170s in PACU requiring IV Labetalol. His blood pressure stabilized post-IV medication. POD#1, he cleared ___ for home. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Please use walker or 2 crutches, wean as able. Mr. ___ is discharged to home with services in stable condition. Medications on Admission: 1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 2. Synvisc (hylan g-f 20) 16 mg/2 mL injection EVERY 8 WEEKS 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. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 6. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 81 mg twice daily. 7. Senna 8.6 mg PO BID 8. HELD- Ibuprofen 400 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until cleared by your surgeon. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left sided medial compartment arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches. Wean assistive device as able. No range of motion restrictions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT LLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: ___
[ "M1712", "Z87891", "F1010", "I973" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left-sided medial knee pain Major Surgical or Invasive Procedure: left partial knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] male with ongoing left-sided medial specific knee pain. This is been refractory to conservative therapy. Unable to tolerate NSAIDs due to gastric irritation, patient presents for left medial unicompartmental arthroplasty. Past Medical History: Shoulder pain, OA right wrist, anxiety disorder, sciatica, migraines, alcohol use disorder 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 no serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 07:30AM BLOOD Hgb-12.4* Hct-37.6* [MASKED] 07:30AM BLOOD Creat-0.8 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: Overnight POD#0, the patient was hypertensive to 170s in PACU requiring IV Labetalol. His blood pressure stabilized post-IV medication. POD#1, he cleared [MASKED] for home. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Please use walker or 2 crutches, wean as able. Mr. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 2. Synvisc (hylan g-f 20) 16 mg/2 mL injection EVERY 8 WEEKS 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. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 6. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 81 mg twice daily. 7. Senna 8.6 mg PO BID 8. HELD- Ibuprofen 400 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until cleared by your surgeon. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left sided medial compartment arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches. Wean assistive device as able. No range of motion restrictions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT LLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "M1712: Unilateral primary osteoarthritis, left knee", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated", "I973: Postprocedural hypertension" ]
10,062,498
20,152,211
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with past medical history significant for prior episodes of diverticulitis in ___ and ___. She presents to the ED today with 2 days of lower abdominal pain. Patient states her pain began ___ after being discharged this past ___ for diverticulitis (d/c'ed on PO Cipro/Flagyl). She describes her pain as a constant 5 out of 10 in the lower midline abd with LLQ quadrant. Her unremitting pain and overall malaise is the cause for todays visit to the ED. In the ED, she triggered for tachycardia 130. On presentation, she was no acute distress. She endorses continued normal nonpainful nonbloody bowel movement, her last being this morning and loss of appetite. She denies fevers/chills, n/v, diarrhea, or prior abdominal surgeries. Her last noted colonoscopy was ___ in which 3 sessile polyps were removed and showed sigmoid diverticulosis. Imaging revealed extensive sigmoid wall thickening and fat stranding, compatible with acute diverticulitis. A 6 mm focal outpouching from the posterior wall of the sigmoid may represent a fluid filed diverticulum or an early intramural abscess. However, there are no drainable fluid collections. Past Medical History: Past Medical History: -HLD Past Surgical History: -Laminectomy -Left Rotator Cuff Repair -Tubal Ligation Social History: ___ Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Admission Physical Exam: Gen: A/O x3, NAD Cardio: RRR, no MRG Pulm: Normal bilateral lung sounds, no wheezing, stridor, or crackles Abd: Soft and distended abdomen. Pt is tender to superficial palpation in the LLQ and lower midline region. No rebound tenderness or guarding. Ext: Pulses palpable bilaterally. ___ perfused. Discharge Physical Exam: VS: 98.5, 135/76, 90, 18, 92 Ra Gen: A&O x3. Lying comfortably in bed NAD CV: HRR NSR Pulm: LS ctab Abd: soft, mildly TTP LLQ Ext: WWP no edema Pertinent Results: ___ 07:05AM BLOOD WBC-8.4 RBC-4.20 Hgb-12.8 Hct-39.5 MCV-94 MCH-30.5 MCHC-32.4 RDW-12.6 RDWSD-43.4 Plt ___ ___ 02:28AM BLOOD WBC-10.7* RBC-4.54 Hgb-14.3 Hct-42.5 MCV-94 MCH-31.5 MCHC-33.6 RDW-12.2 RDWSD-41.9 Plt ___ ___ 07:05AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-139 K-4.6 Cl-101 HCO3-27 AnGap-11 ___ 02:28AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-140 K-5.1 Cl-102 HCO3-23 AnGap-15 ___ 02:28AM BLOOD ALT-63* AST-42* AlkPhos-66 TotBili-0.3 ___ 07:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 ___ 02:28AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.3 Mg-2.1 Imaging: CT abdomen pelvis ___: Improving sigmoid diverticulitis compared to ___. No drainable collections. No pneumoperitoneum. Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed improving sigmoid diverticulitis, no drainable collections. WBC was elevated at 12.9. The patient was hemodynamically stable. She was admitted for observation and serial abdominal exams. Her antibiotics were switched to augmentin. On HD2, her WBC was normal and her pain was better. She was tolerating a regular diet. 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. She was given a new prescription to complete a course of augmentin and was scheduled to follow-up in ___ clinic for operative planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Ciprofloxacin HCl 500 mg PO Q12H 3. MetroNIDAZOLE 500 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 9 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*18 Tablet Refills:*0 3. Atorvastatin 20 mg PO QPM 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Sigmoid diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with abdominal pain. Your CT scan showed improving sigmoid diverticulitis compared to ___ scan with no drainable collections. Your antibiotics were changed from cipro/flagyl to augmentin. You will be given a prescription to complete a 10-day course of this. Your pain has improved and you are tolerating a regular diet. You are ready to be discharged home to continue your recovery. You should follow-up in clinic to discuss surgery at your scheduled appointment. 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: ___
[ "K5732", "E785", "Z87891", "Z86010", "E7800", "Z8379" ]
Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old female with past medical history significant for prior episodes of diverticulitis in [MASKED] and [MASKED]. She presents to the ED today with 2 days of lower abdominal pain. Patient states her pain began [MASKED] after being discharged this past [MASKED] for diverticulitis (d/c'ed on PO Cipro/Flagyl). She describes her pain as a constant 5 out of 10 in the lower midline abd with LLQ quadrant. Her unremitting pain and overall malaise is the cause for todays visit to the ED. In the ED, she triggered for tachycardia 130. On presentation, she was no acute distress. She endorses continued normal nonpainful nonbloody bowel movement, her last being this morning and loss of appetite. She denies fevers/chills, n/v, diarrhea, or prior abdominal surgeries. Her last noted colonoscopy was [MASKED] in which 3 sessile polyps were removed and showed sigmoid diverticulosis. Imaging revealed extensive sigmoid wall thickening and fat stranding, compatible with acute diverticulitis. A 6 mm focal outpouching from the posterior wall of the sigmoid may represent a fluid filed diverticulum or an early intramural abscess. However, there are no drainable fluid collections. Past Medical History: Past Medical History: -HLD Past Surgical History: -Laminectomy -Left Rotator Cuff Repair -Tubal Ligation Social History: [MASKED] Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Admission Physical Exam: Gen: A/O x3, NAD Cardio: RRR, no MRG Pulm: Normal bilateral lung sounds, no wheezing, stridor, or crackles Abd: Soft and distended abdomen. Pt is tender to superficial palpation in the LLQ and lower midline region. No rebound tenderness or guarding. Ext: Pulses palpable bilaterally. [MASKED] perfused. Discharge Physical Exam: VS: 98.5, 135/76, 90, 18, 92 Ra Gen: A&O x3. Lying comfortably in bed NAD CV: HRR NSR Pulm: LS ctab Abd: soft, mildly TTP LLQ Ext: WWP no edema Pertinent Results: [MASKED] 07:05AM BLOOD WBC-8.4 RBC-4.20 Hgb-12.8 Hct-39.5 MCV-94 MCH-30.5 MCHC-32.4 RDW-12.6 RDWSD-43.4 Plt [MASKED] [MASKED] 02:28AM BLOOD WBC-10.7* RBC-4.54 Hgb-14.3 Hct-42.5 MCV-94 MCH-31.5 MCHC-33.6 RDW-12.2 RDWSD-41.9 Plt [MASKED] [MASKED] 07:05AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-139 K-4.6 Cl-101 HCO3-27 AnGap-11 [MASKED] 02:28AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-140 K-5.1 Cl-102 HCO3-23 AnGap-15 [MASKED] 02:28AM BLOOD ALT-63* AST-42* AlkPhos-66 TotBili-0.3 [MASKED] 07:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 [MASKED] 02:28AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.3 Mg-2.1 Imaging: CT abdomen pelvis [MASKED]: Improving sigmoid diverticulitis compared to [MASKED]. No drainable collections. No pneumoperitoneum. Brief Hospital Course: The patient was admitted to the General Surgical Service on [MASKED] for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed improving sigmoid diverticulitis, no drainable collections. WBC was elevated at 12.9. The patient was hemodynamically stable. She was admitted for observation and serial abdominal exams. Her antibiotics were switched to augmentin. On HD2, her WBC was normal and her pain was better. She was tolerating a regular diet. 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. She was given a new prescription to complete a course of augmentin and was scheduled to follow-up in [MASKED] clinic for operative planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Ciprofloxacin HCl 500 mg PO Q12H 3. MetroNIDAZOLE 500 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 9 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*18 Tablet Refills:*0 3. Atorvastatin 20 mg PO QPM 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Sigmoid diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] with abdominal pain. Your CT scan showed improving sigmoid diverticulitis compared to [MASKED] scan with no drainable collections. Your antibiotics were changed from cipro/flagyl to augmentin. You will be given a prescription to complete a 10-day course of this. Your pain has improved and you are tolerating a regular diet. You are ready to be discharged home to continue your recovery. You should follow-up in clinic to discuss surgery at your scheduled appointment. 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]
[]
[ "E785", "Z87891" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z86010: Personal history of colonic polyps", "E7800: Pure hypercholesterolemia, unspecified", "Z8379: Family history of other diseases of the digestive system" ]
10,062,498
23,893,278
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Attending: ___. Chief Complaint: Lower abdominal pain and dyschezia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___, is a ___ year old female with past medical history significant for 2 prior episodes of diverticulitis, ___ and ___, who presents to the ED today with 4 days of lower abdominal pain and dyschezia. Patient states her pain began ___, but related it a UTI she was being treated for the prior ___ she had increased lower abdominal pain and dyschezia with normal bowel movements. ___ her pain again increased and she opted to see her PCP who placed her on a PO course of Cipro/Flagyl. Her unremitting pain and overall malaise is the cause for todays visit to the ED. Past Medical History: ___ s/p removal Social History: ___ Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: VS: 98.5 F 149/93 86 16 97 RA Cardio: Normal S1, S2 Pulmonary: CTAB GI: soft, ND, NT (much improved since admission) GU: WNL MSK: 2+ TP and DP, no edema Pertinent Results: ___ 02:40PM BLOOD Lactate-1.1 ___ 04:46PM BLOOD Albumin-4.0 ___ 09:15AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 ___ 05:05AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 ___ 06:34AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0 ___ 04:46PM BLOOD Lipase-38 ___ 04:46PM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-143 K-4.0 Cl-106 HCO3-22 AnGap-15 ___ 09:15AM BLOOD Glucose-123* UreaN-7 Creat-0.7 Na-145 K-3.9 Cl-106 HCO3-26 AnGap-13 ___ 05:05AM BLOOD Glucose-112* UreaN-5* Creat-0.6 Na-146 K-3.8 Cl-109* HCO3-26 AnGap-11 ___ 06:34AM BLOOD Glucose-97 UreaN-5* Creat-0.7 Na-146 K-3.8 Cl-108 HCO3-24 AnGap-14 ___ 02:36PM BLOOD Plt ___ ___ 09:15AM BLOOD Plt ___ ___ 05:05AM BLOOD Plt ___ ___ 06:34AM BLOOD Plt ___ ___ 02:36PM BLOOD Neuts-84.5* Lymphs-6.1* Monos-8.4 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.68* AbsLymp-0.70* AbsMono-0.96* AbsEos-0.02* AbsBaso-0.04 ___ 09:15AM BLOOD Neuts-72.4* Lymphs-14.1* Monos-11.4 Eos-1.1 Baso-0.9 Im ___ AbsNeut-5.08 AbsLymp-0.99* AbsMono-0.80 AbsEos-0.08 AbsBaso-0.06 ___ 02:36PM BLOOD WBC-11.5* RBC-4.41 Hgb-13.6 Hct-41.2 MCV-93 MCH-30.8 MCHC-33.0 RDW-12.0 RDWSD-41.2 Plt ___ ___ 09:15AM BLOOD WBC-7.0 RBC-3.77* Hgb-11.5 Hct-36.2 MCV-96 MCH-30.5 MCHC-31.8* RDW-12.2 RDWSD-43.2 Plt ___ ___ 05:05AM BLOOD WBC-4.4 RBC-3.72* Hgb-11.5 Hct-35.0 MCV-94 MCH-30.9 MCHC-32.9 RDW-11.9 RDWSD-40.9 Plt ___ ___ 06:34AM BLOOD WBC-4.8 RBC-3.91 Hgb-12.1 Hct-36.5 MCV-93 MCH-30.9 MCHC-33.2 RDW-12.0 RDWSD-41.1 Plt ___ Brief Hospital Course: Ms. ___ is a ___ year old female with past medical history significant for 2 prior episodes of diverticulitis, ___ and ___, who was admitted for conservative management of symptomatic acute uncomplicated diverticulitis. On admission (___), she had a low grade temperature with an elevated WBC. The admission CT showed acute uncomplicated diverticulitis. She was started on IV ciprofloxacin and metronidazole. She was switched to PO ciprofloxacin and metronidazole on ___. On discharge, she was afebrile, hemodynamically stable, with a normal WBC range. She was tolerating a regular diet, urinating, having regular bowel movements and denies abdominal pain. She is to complete her antibiotics as prescribed and follow up in clinic in ___ weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 2. MetroNIDAZOLE 500 mg PO TID 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 5. Atorvastatin 20 mg PO QPM 6. Naproxen 250 mg PO Q12H:PRN Pain - Mild 7. Ciprofloxacin HCl 500 mg PO Q12H 8. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 2. Atorvastatin 20 mg PO QPM 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 7. Naproxen 250 mg PO Q12H:PRN Pain - Mild 8. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute uncomplicated diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, you were admitted to ___ ___ for recurrent ___ episode since ___ acute uncomplicated diverticulitis. You have recovered well and are ready for discharge. You will need to continue your antibiotics are prescribed and follow up in clinic. 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. Thank you for letting us take care of you! Followup Instructions: ___
[ "K5720", "Z87891", "E785" ]
Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Chief Complaint: Lower abdominal pain and dyschezia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED], is a [MASKED] year old female with past medical history significant for 2 prior episodes of diverticulitis, [MASKED] and [MASKED], who presents to the ED today with 4 days of lower abdominal pain and dyschezia. Patient states her pain began [MASKED], but related it a UTI she was being treated for the prior [MASKED] she had increased lower abdominal pain and dyschezia with normal bowel movements. [MASKED] her pain again increased and she opted to see her PCP who placed her on a PO course of Cipro/Flagyl. Her unremitting pain and overall malaise is the cause for todays visit to the ED. Past Medical History: [MASKED] s/p removal Social History: [MASKED] Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: VS: 98.5 F 149/93 86 16 97 RA Cardio: Normal S1, S2 Pulmonary: CTAB GI: soft, ND, NT (much improved since admission) GU: WNL MSK: 2+ TP and DP, no edema Pertinent Results: [MASKED] 02:40PM BLOOD Lactate-1.1 [MASKED] 04:46PM BLOOD Albumin-4.0 [MASKED] 09:15AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 [MASKED] 05:05AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 [MASKED] 06:34AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0 [MASKED] 04:46PM BLOOD Lipase-38 [MASKED] 04:46PM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-143 K-4.0 Cl-106 HCO3-22 AnGap-15 [MASKED] 09:15AM BLOOD Glucose-123* UreaN-7 Creat-0.7 Na-145 K-3.9 Cl-106 HCO3-26 AnGap-13 [MASKED] 05:05AM BLOOD Glucose-112* UreaN-5* Creat-0.6 Na-146 K-3.8 Cl-109* HCO3-26 AnGap-11 [MASKED] 06:34AM BLOOD Glucose-97 UreaN-5* Creat-0.7 Na-146 K-3.8 Cl-108 HCO3-24 AnGap-14 [MASKED] 02:36PM BLOOD Plt [MASKED] [MASKED] 09:15AM BLOOD Plt [MASKED] [MASKED] 05:05AM BLOOD Plt [MASKED] [MASKED] 06:34AM BLOOD Plt [MASKED] [MASKED] 02:36PM BLOOD Neuts-84.5* Lymphs-6.1* Monos-8.4 Eos-0.2* Baso-0.3 Im [MASKED] AbsNeut-9.68* AbsLymp-0.70* AbsMono-0.96* AbsEos-0.02* AbsBaso-0.04 [MASKED] 09:15AM BLOOD Neuts-72.4* Lymphs-14.1* Monos-11.4 Eos-1.1 Baso-0.9 Im [MASKED] AbsNeut-5.08 AbsLymp-0.99* AbsMono-0.80 AbsEos-0.08 AbsBaso-0.06 [MASKED] 02:36PM BLOOD WBC-11.5* RBC-4.41 Hgb-13.6 Hct-41.2 MCV-93 MCH-30.8 MCHC-33.0 RDW-12.0 RDWSD-41.2 Plt [MASKED] [MASKED] 09:15AM BLOOD WBC-7.0 RBC-3.77* Hgb-11.5 Hct-36.2 MCV-96 MCH-30.5 MCHC-31.8* RDW-12.2 RDWSD-43.2 Plt [MASKED] [MASKED] 05:05AM BLOOD WBC-4.4 RBC-3.72* Hgb-11.5 Hct-35.0 MCV-94 MCH-30.9 MCHC-32.9 RDW-11.9 RDWSD-40.9 Plt [MASKED] [MASKED] 06:34AM BLOOD WBC-4.8 RBC-3.91 Hgb-12.1 Hct-36.5 MCV-93 MCH-30.9 MCHC-33.2 RDW-12.0 RDWSD-41.1 Plt [MASKED] Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female with past medical history significant for 2 prior episodes of diverticulitis, [MASKED] and [MASKED], who was admitted for conservative management of symptomatic acute uncomplicated diverticulitis. On admission ([MASKED]), she had a low grade temperature with an elevated WBC. The admission CT showed acute uncomplicated diverticulitis. She was started on IV ciprofloxacin and metronidazole. She was switched to PO ciprofloxacin and metronidazole on [MASKED]. On discharge, she was afebrile, hemodynamically stable, with a normal WBC range. She was tolerating a regular diet, urinating, having regular bowel movements and denies abdominal pain. She is to complete her antibiotics as prescribed and follow up in clinic in [MASKED] weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 2. MetroNIDAZOLE 500 mg PO TID 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 5. Atorvastatin 20 mg PO QPM 6. Naproxen 250 mg PO Q12H:PRN Pain - Mild 7. Ciprofloxacin HCl 500 mg PO Q12H 8. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 2. Atorvastatin 20 mg PO QPM 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 7. Naproxen 250 mg PO Q12H:PRN Pain - Mild 8. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute uncomplicated diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], you were admitted to [MASKED] [MASKED] for recurrent [MASKED] episode since [MASKED] acute uncomplicated diverticulitis. You have recovered well and are ready for discharge. You will need to continue your antibiotics are prescribed and follow up in clinic. 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. Thank you for letting us take care of you! Followup Instructions: [MASKED]
[]
[ "Z87891", "E785" ]
[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified" ]
10,062,498
24,180,052
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bacitracin / Codeine Attending: ___. Chief Complaint: ___ w/ recurrent diverticulitis s/p robotic sigmoidectomy Major Surgical or Invasive Procedure: Robotic sigmoid colectomy with mobilization of splenic flexure History of Present Illness: ___ is a ___ w/ recent hx of multiple episodes of diverticulitis who presented for robotic sigmoid resection. She has had three episodes of sigmoid diverticulitis over past ___ years, with 2 episodes ___ and most recent one) requiring hospitalization. Her last hospitalization was complicated by readmission for recurrent abdominal pain and while her prior episodes resolved on cipro and flagyl, she was switched to augmentin with improvement. She was seen at the ___ clinic on ___, during which she elected to proceed with sigmoid resection for the prevention of future episodes of diverticulitis, after a lengthy discussion of the risks and benefits of the procedure. At the time of her presentation for this surgery, she denies any current symptoms. Past Medical History: Past Medical History: -HLD Past Surgical History: -Laminectomy -Left Rotator Cuff Repair -Tubal Ligation Social History: ___ Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Gen: Appears well, AAOx3 CV: RRR Resp: Normal effort, no distress Abdomen: Soft, mildly distended, appropriately tender in left more than right abdomen, no rebound or guarding Wound: Incisions C/D/I, covered with Dermabond Ext: Warm, well perfused, no edema Pertinent Results: ___ 11:00AM BLOOD WBC-12.6* RBC-3.89* Hgb-11.5 Hct-35.9 MCV-92 MCH-29.6 MCHC-32.0 RDW-12.5 RDWSD-42.2 Plt ___ ___ 11:00AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-104 HCO___ AnGap-11 ___ 11:00AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.___ presented to pre-op holding at ___ on ___ for a robotic sigmoidectomy due to recurrent diverticulitis. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on dilaudid PCA, and later, Tylenol and oxycodone. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. She had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially allowed to have sips after the procedure. The patient was advanced to CLD by POD1, and later on POD1, advanced to a low residue regular diet. She tolerated diet advancement well. She was passing flatus by POD1. Patient's intake and output were closely monitored. GU: The patient had a Foley catheter that was removed prior to discharge. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever, of which there was none. Heme: The patient received lovenox and ___ dyne boots during this stay. She was encouraged to get up and ambulate as early and as often as possible. The patient is being discharged on prophylactic Lovenox. On ___ (POD2) the patient was discharged to home. At time of discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen ___ mg PO Q8H 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 4. Atorvastatin 20 mg PO QPM 5. Omeprazole 20 mg PO DAILY 6. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 7. Vitamin D 400 UNIT PO DAILY 8. Naproxen 250 mg PO Q12H Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*27 Syringe Refills:*0 2. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 3. Acetaminophen ___ mg PO Q8H 4. Atorvastatin 20 mg PO QPM 5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Naproxen 250 mg PO Q12H 9. Omeprazole 20 mg PO DAILY 10. Vitamin D 400 UNIT 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: Dear Ms. ___, You were admitted to the hospital after a laparoscopic sigmoid colectomy for surgical management of your diverticulitis. You have recovered from this procedure and you are now ready to return home. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to discharge which is acceptable; however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. However, you may have loose stool and passing of small amounts of dark, old appearing blood. If you notice that you are passing bright red blood with bowel movements or having large amounts of loose stool without improvement please call the office or go to the emergency room. While taking narcotic pain medications you are at risk for constipation, please take an over the counter stool softener such as Colace. You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures. It is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/foul smelling drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. If you have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain is expected after surgery. This will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol (___) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days. Please take Advil with food. You are being discharged home on Lovenox injections to prevent blood clots after surgery. You will take this medication for a total of 30 days (including doses in hospital), please finish the entire prescription. Please monitor for any signs of bleeding: fast heart rate, bloody bowel movements, abdominal pain, bruising, feeling faint or weak. If you have any of these symptoms please call our office or seek medical attention immediately. Please avoid any contact activity and take extra caution to avoid falling while taking Lovenox. You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: ___
[ "K5732", "E785", "Z85828", "Z87891" ]
Allergies: Bacitracin / Codeine Chief Complaint: [MASKED] w/ recurrent diverticulitis s/p robotic sigmoidectomy Major Surgical or Invasive Procedure: Robotic sigmoid colectomy with mobilization of splenic flexure History of Present Illness: [MASKED] is a [MASKED] w/ recent hx of multiple episodes of diverticulitis who presented for robotic sigmoid resection. She has had three episodes of sigmoid diverticulitis over past [MASKED] years, with 2 episodes [MASKED] and most recent one) requiring hospitalization. Her last hospitalization was complicated by readmission for recurrent abdominal pain and while her prior episodes resolved on cipro and flagyl, she was switched to augmentin with improvement. She was seen at the [MASKED] clinic on [MASKED], during which she elected to proceed with sigmoid resection for the prevention of future episodes of diverticulitis, after a lengthy discussion of the risks and benefits of the procedure. At the time of her presentation for this surgery, she denies any current symptoms. Past Medical History: Past Medical History: -HLD Past Surgical History: -Laminectomy -Left Rotator Cuff Repair -Tubal Ligation Social History: [MASKED] Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Gen: Appears well, AAOx3 CV: RRR Resp: Normal effort, no distress Abdomen: Soft, mildly distended, appropriately tender in left more than right abdomen, no rebound or guarding Wound: Incisions C/D/I, covered with Dermabond Ext: Warm, well perfused, no edema Pertinent Results: [MASKED] 11:00AM BLOOD WBC-12.6* RBC-3.89* Hgb-11.5 Hct-35.9 MCV-92 MCH-29.6 MCHC-32.0 RDW-12.5 RDWSD-42.2 Plt [MASKED] [MASKED] 11:00AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-104 HCO AnGap-11 [MASKED] 11:00AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.[MASKED] presented to pre-op holding at [MASKED] on [MASKED] for a robotic sigmoidectomy due to recurrent diverticulitis. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on dilaudid PCA, and later, Tylenol and oxycodone. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. She had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially allowed to have sips after the procedure. The patient was advanced to CLD by POD1, and later on POD1, advanced to a low residue regular diet. She tolerated diet advancement well. She was passing flatus by POD1. Patient's intake and output were closely monitored. GU: The patient had a Foley catheter that was removed prior to discharge. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever, of which there was none. Heme: The patient received lovenox and [MASKED] dyne boots during this stay. She was encouraged to get up and ambulate as early and as often as possible. The patient is being discharged on prophylactic Lovenox. On [MASKED] (POD2) the patient was discharged to home. At time of discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen [MASKED] mg PO Q8H 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 4. Atorvastatin 20 mg PO QPM 5. Omeprazole 20 mg PO DAILY 6. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 7. Vitamin D 400 UNIT PO DAILY 8. Naproxen 250 mg PO Q12H Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*27 Syringe Refills:*0 2. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 3. Acetaminophen [MASKED] mg PO Q8H 4. Atorvastatin 20 mg PO QPM 5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Naproxen 250 mg PO Q12H 9. Omeprazole 20 mg PO DAILY 10. Vitamin D 400 UNIT 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: Dear Ms. [MASKED], You were admitted to the hospital after a laparoscopic sigmoid colectomy for surgical management of your diverticulitis. You have recovered from this procedure and you are now ready to return home. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to discharge which is acceptable; however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. However, you may have loose stool and passing of small amounts of dark, old appearing blood. If you notice that you are passing bright red blood with bowel movements or having large amounts of loose stool without improvement please call the office or go to the emergency room. While taking narcotic pain medications you are at risk for constipation, please take an over the counter stool softener such as Colace. You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures. It is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/foul smelling drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. If you have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain is expected after surgery. This will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol ([MASKED]) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days. Please take Advil with food. You are being discharged home on Lovenox injections to prevent blood clots after surgery. You will take this medication for a total of 30 days (including doses in hospital), please finish the entire prescription. Please monitor for any signs of bleeding: fast heart rate, bloody bowel movements, abdominal pain, bruising, feeling faint or weak. If you have any of these symptoms please call our office or seek medical attention immediately. Please avoid any contact activity and take extra caution to avoid falling while taking Lovenox. You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: [MASKED]
[]
[ "E785", "Z87891" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "E785: Hyperlipidemia, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence" ]
10,062,498
28,313,359
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with no sig PMH presents w/ ___ episode uncomplicated diverticulitis. She was presents to ED ___ w/ suprapubic pain and LLQ for 2 days. She was ED obs'd ___ however this AM on PO challenge she had worsening abdominal pain. She denies fevers/chills nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough. Her last colonoscopy was ___ which she reportedly had some polyps removed w/ ___ year f/u scheduled. Past Medical History: ___ s/p removal Social History: ___ Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Physical Exam: upon admission: ___ Vitals: 98.6 90 129/68 14 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: NRD ABD: Soft, nondistended, TTP LLQ w/ mild guarding, no rebound. Ext: No ___ edema, ___ warm and well perfused Physical examination upon discharge: ___: General: NAD vital signs: 97.8, hr=71, bp=123/68, rr=18, 97% room air CV: ns1, s2, no murmurs LUNGS: clear ABDOMEN: hypoactive BS, soft, tender, no hepatomegaly EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 08:35AM BLOOD WBC-10.3* RBC-3.77* Hgb-12.0 Hct-35.8 MCV-95 MCH-31.8 MCHC-33.5 RDW-12.2 RDWSD-42.3 Plt ___ ___ 12:35PM BLOOD WBC-12.7*# RBC-4.45 Hgb-14.2 Hct-41.7 MCV-94 MCH-31.9 MCHC-34.1 RDW-12.0 RDWSD-41.3 Plt ___ ___ 08:35AM BLOOD ___ PTT-29.8 ___ ___ 06:15AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.4 ___: ct abd/pelvis: Acute sigmoid diverticulitis with severe inflammation and a small amount of free fluid, without organized collection or free air. ___ 12:35 pm URINE ****** ___ Urgent Care ******. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: ___ year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. Cat scan imaging showed acute sigmoid diverticulitis with severe inflammation and a small amount of free fluid, without an organized collection or free air. The patient was placed on bowel rest and started on a course of ciprofloxacin and flagyl. She underwent serial abdominal examinations and monitoring of her white blood cell count. The patient was advanced to a regular diet after her abdominal pain decreased and she had return of bowel function. The patient was discharged home on HD #5. Her vital signs were stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. Her abdominal pain had decreased in severity. The patient was discharged on a 10 day course of ciprofloxacin and flagyl. Follow-up appointments were made in the acute care clinic. Discharge instructions were reviewed and questions answered. Medications on Admission: restates eye drops omeprazole 20 mg daily PRN with naproxen naproxen 250 mg q 12 hours for knee and lower back pain fluticasone nasal spray 1 spray twice daily to each nostil citracal and vit D3 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H last dose ___ RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) 250 mg calcium- 500 unit oral DAILY 4. MetroNIDAZOLE 500 mg PO TID last dose ___ RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 5. Fluticasone Propionate NASAL 1 SPRY NU BID 1 spray each nostil 6. Naproxen 250 mg PO Q12H PRN for knee and lower back pain please take with food 7. Omeprazole 20 mg PO DAILY PRN when taking naproxen 8. Restasis 0.05 % ophthalmic BID 1 gtt both eyes 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: Ms. ___, ___ were admitted to the Acute Care Surgery service at the ___ ___ for management of your diverticulitis. ___ have been treated with IV antibiotics and ___ are now ready to be discharged home to continue your recovery. ___ are being discharged with the following instructions. ___ will be discharged on a course of antibiotics for 10 days. If ___ have difficulty tolerating the medication, please call ___ clinic # ___: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: ___ experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If ___ are vomiting and cannot keep down fluids or your medications. ___ 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. ___ see blood or dark/black material when ___ vomit or have a bowel movement. ___ experience burning when ___ urinate, have blood in your urine, or experience a discharge. ___ 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 ___. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: ___
[ "K5732", "M25569", "M545", "Z87891" ]
Allergies: Bacitracin / Codeine / Iodine Containing Agents Classifier Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old female with no sig PMH presents w/ [MASKED] episode uncomplicated diverticulitis. She was presents to ED [MASKED] w/ suprapubic pain and LLQ for 2 days. She was ED obs'd [MASKED] however this AM on PO challenge she had worsening abdominal pain. She denies fevers/chills nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough. Her last colonoscopy was [MASKED] which she reportedly had some polyps removed w/ [MASKED] year f/u scheduled. Past Medical History: [MASKED] s/p removal Social History: [MASKED] Family History: Brother w/ diverticulitis, denies hx of GI malignancy Physical Exam: Physical Exam: upon admission: [MASKED] Vitals: 98.6 90 129/68 14 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: NRD ABD: Soft, nondistended, TTP LLQ w/ mild guarding, no rebound. Ext: No [MASKED] edema, [MASKED] warm and well perfused Physical examination upon discharge: [MASKED]: General: NAD vital signs: 97.8, hr=71, bp=123/68, rr=18, 97% room air CV: ns1, s2, no murmurs LUNGS: clear ABDOMEN: hypoactive BS, soft, tender, no hepatomegaly EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear Pertinent Results: [MASKED] 08:35AM BLOOD WBC-10.3* RBC-3.77* Hgb-12.0 Hct-35.8 MCV-95 MCH-31.8 MCHC-33.5 RDW-12.2 RDWSD-42.3 Plt [MASKED] [MASKED] 12:35PM BLOOD WBC-12.7*# RBC-4.45 Hgb-14.2 Hct-41.7 MCV-94 MCH-31.9 MCHC-34.1 RDW-12.0 RDWSD-41.3 Plt [MASKED] [MASKED] 08:35AM BLOOD [MASKED] PTT-29.8 [MASKED] [MASKED] 06:15AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.4 [MASKED]: ct abd/pelvis: Acute sigmoid diverticulitis with severe inflammation and a small amount of free fluid, without organized collection or free air. [MASKED] 12:35 pm URINE ****** [MASKED] Urgent Care ******. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: [MASKED] year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. Cat scan imaging showed acute sigmoid diverticulitis with severe inflammation and a small amount of free fluid, without an organized collection or free air. The patient was placed on bowel rest and started on a course of ciprofloxacin and flagyl. She underwent serial abdominal examinations and monitoring of her white blood cell count. The patient was advanced to a regular diet after her abdominal pain decreased and she had return of bowel function. The patient was discharged home on HD #5. Her vital signs were stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. Her abdominal pain had decreased in severity. The patient was discharged on a 10 day course of ciprofloxacin and flagyl. Follow-up appointments were made in the acute care clinic. Discharge instructions were reviewed and questions answered. Medications on Admission: restates eye drops omeprazole 20 mg daily PRN with naproxen naproxen 250 mg q 12 hours for knee and lower back pain fluticasone nasal spray 1 spray twice daily to each nostil citracal and vit D3 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H last dose [MASKED] RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) 250 mg calcium- 500 unit oral DAILY 4. MetroNIDAZOLE 500 mg PO TID last dose [MASKED] RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 5. Fluticasone Propionate NASAL 1 SPRY NU BID 1 spray each nostil 6. Naproxen 250 mg PO Q12H PRN for knee and lower back pain please take with food 7. Omeprazole 20 mg PO DAILY PRN when taking naproxen 8. Restasis 0.05 % ophthalmic BID 1 gtt both eyes 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: Ms. [MASKED], [MASKED] were admitted to the Acute Care Surgery service at the [MASKED] [MASKED] for management of your diverticulitis. [MASKED] have been treated with IV antibiotics and [MASKED] are now ready to be discharged home to continue your recovery. [MASKED] are being discharged with the following instructions. [MASKED] will be discharged on a course of antibiotics for 10 days. If [MASKED] have difficulty tolerating the medication, please call [MASKED] clinic # [MASKED]: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: [MASKED] experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If [MASKED] are vomiting and cannot keep down fluids or your medications. [MASKED] 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. [MASKED] see blood or dark/black material when [MASKED] vomit or have a bowel movement. [MASKED] experience burning when [MASKED] urinate, have blood in your urine, or experience a discharge. [MASKED] 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 [MASKED]. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "M25569: Pain in unspecified knee", "M545: Low back pain", "Z87891: Personal history of nicotine dependence" ]
10,062,617
23,079,060
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sulfur dioxide / cephalexin Attending: ___ Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with a PMH significant for SSS s/p pacemaker placement who presents after an episode of unresponsiveness while at home yesterday evening. The patient was recently at ___ for a pacemaker generator change after he was found to have low battery life during a routine follow up in clinic. He received no sedation and had an uncomplicated procedure and was discharged home the same day in the afternoon. He was started on clindamycin 800 mg Q8H on discharge. Yesterday evening at home, he was eating dinner with his wife when he suddenly became unresponsive when his wife turned around to get him dessert. He had his eyes open at the time but would not respond to voice or command. His daughter came into the room and checked his pulse, which was noted to be in the ___. EMS was called and on their arrival, they found his BP to be in the ___. He became more responsive en route with EMS, and arrived alert to the ED. In the ED initial vitals were: HR 60 BP 106/52 RR 15 SAT 99% RA. The patient was documented to be hypotensive to 81/48 at 21:50 day of arrival. EKG noted by ED staff to be AV paced at 60 BPM with LAD and LBBB. Labs were notable for trop-T of 0.10 then 0.03. Lactate was 1.9. CXR was negative for any acute processes. UA was normal. The patient received 250 mL NS, levofloxacin 750 mg IV, aspirin 324 mg PO, and heparin drip. EP was consulted and interrogated the patient's pacemaker, which was functioning normally. The lower rate was increased to 70 BPM. He was monitored overnight before admission to the floor today. On the floor, he reports feeling well with no specific complaints. He does not remember the events of yesterday. He asked that I speak with his wife for more information. He does not recall having any chest pain, palpitations, dyspnea, cough, fevers, or chills. He does mention that he needs his food pureed at home. Past Medical History: - CHF (EF 45%-50% on TTE ___ - Sick sinus syndrome status post pacemaker placement in ___ at ___ (generator change in ___ due to recurrent syncope, found to have premature battery failure and an elevated RV pacing threshold) - Aortic insufficiency - Aortic stenosis, moderate - Thoracic aortic aneurysm - Paroxysmal supraventricular tachycardia (atrial fibrillation) - Stage 3 CKD - Hypertension - Diverticulosis - Colonic adenoma - Benign prostatic hypertrophy - Osteopenia - Dry macular degeneration - Subclinical hypothyroidism - Obstructive sleep apnea - Unsteady gait with history of syncope and falls - Venous stasis - Tremor Social History: ___ Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 97.8 BP 138/76 HR 70 RR 18 O2 SAT 98% on RA; Wt 74.8 kg by bed scale GENERAL: Frail appearing elderly male in NAD. Oriented to person and time after consulting the wall calendar. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 6-7 cm. CARDIAC: RRR, normal S1, S2. ___ ejection murmur at the bases and no appreciated radiation to the carotids. LUNGS: Respiration is unlabored, no accessory muscle use. Bibasilar inspiratory crackles. ABDOMEN: Soft, nontender, nondistended. No hepatomegaly. EXTREMITIES: Cool distal extremities to touch, trace edema in the lower extremities SKIN: Evidence of venous stasis changes in the lower extremities, some excoriations and throughout the body in particular on the back with various stages of healing PULSES: Radial pulses full bilaterally, 1+ ___ pulses, DP only by Doppler DISCHARGE PHYSICAL EXAMINATION: VS: T afebrile BP 130-139/77 HR 70 RR 16 O2 SAT 95-98% on RA; Wt 73 kg bed scale <-- 74.8 kg by bed scale GENERAL: Frail appearing elderly male in NAD. Mood, affect appropriate. HEENT: NCAT. CARDIAC: RRR, normal S1, S2. ___ ejection murmur at the bases LUNGS: Respiration is unlabored, no accessory muscle use. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Cool distal extremities to touch, trace edema in the lower extremities. SKIN: Evidence of venous stasis changes in the lower extremities, some excoriations and throughout the body in particular on the back with various stages of healing PULSES: 1+ ___ pulses, DP only by Doppler Pertinent Results: ADMISSION LABS ============== ___ 09:19PM ___ PTT-27.5 ___ ___ 09:19PM PLT COUNT-183 ___ 09:19PM NEUTS-65.5 ___ MONOS-7.9 EOS-0.5* BASOS-0.4 IM ___ AbsNeut-5.39 AbsLymp-2.07 AbsMono-0.65 AbsEos-0.04 AbsBaso-0.03 ___ 09:19PM WBC-8.2 RBC-3.80*# HGB-12.4*# HCT-36.7*# MCV-97 MCH-32.6* MCHC-33.8 RDW-13.9 RDWSD-49.4* ___ 09:19PM DIGOXIN-0.5* ___ 09:19PM T4-5.4 T3-73* FREE T4-0.9* ___ 09:19PM TSH-9.8* ___ 09:19PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.0 ___ 09:19PM CK-MB-5 cTropnT-0.10* ___ 09:19PM LIPASE-33 ___ 09:19PM ALT(SGPT)-10 AST(SGOT)-18 CK(CPK)-58 ALK PHOS-108 TOT BILI-0.5 ___ 09:19PM estGFR-Using this ___ 09:19PM GLUCOSE-114* UREA N-23* CREAT-1.2 SODIUM-131* POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-29 ANION GAP-13 ___ 09:20PM LACTATE-1.9 ___ 11:00PM URINE MUCOUS-OCC ___ 11:00PM URINE HYALINE-14* ___ 11:00PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:00PM URINE UHOLD-HOLD ___ 11:00PM URINE OSMOLAL-360 ___ 11:00PM URINE HOURS-RANDOM UREA N-495 CREAT-80 SODIUM-26 POTASSIUM-61 CHLORIDE-38 ___ 08:30AM CK-MB-4 cTropnT-0.03* ___ 08:30AM CK(CPK)-39* ___ 03:30PM MAGNESIUM-2.0 ___ 03:30PM UREA N-21* CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-30 ANION GAP-11 PERTINENT LABS ============== ___ 09:19PM BLOOD Digoxin-0.5* ___ 06:00AM BLOOD Cortsol-9.1 ___ 09:19PM BLOOD T4-5.4 T3-73* Free T4-0.9* ___ 09:19PM BLOOD TSH-9.8* ___ 09:19PM BLOOD CK-MB-5 cTropnT-0.10* ___ 08:30AM BLOOD CK-MB-4 cTropnT-0.03* DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-6.1 RBC-3.50* Hgb-11.3* Hct-33.3* MCV-95 MCH-32.3* MCHC-33.9 RDW-14.1 RDWSD-48.7* Plt ___ ___ 06:00AM BLOOD Glucose-84 UreaN-17 Creat-0.8 Na-132* K-3.9 Cl-97 HCO3-27 AnGap-12 ___ 06:00AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8 RADIOLOGY ========= ___ CHEST (PORTABLE AP) FINDINGS: Left-sided pacer device is re- demonstrated with leads terminating in unchanged positions in the right atrium and right ventricle. Severe cardiomegaly is unchanged. The aorta remains tortuous with atherosclerotic calcifications at the knob. Mediastinal and hilar contours are similar. Lungs appear hyperinflated. Linear opacities in the lung bases likely reflect areas of scarring and atelectasis. No focal consolidation, pleural effusion or pneumothorax is detected. IMPRESSION: No acute cardiopulmonary abnormality. CARDIAC STUDIES =============== ___ ECHO Conclusions The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%) secondary to mild global hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate-severe aortic valve stenosis (valve area = 1.0cm2; indexed stroke volume 26 ml/m2; dimensionless index 0.31). Mild-moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the degree of calcific aortic stenosis has progressed to moderate-severe (moderate previously). Global left ventricular systolic function is more vigorous. There is slightly less aortic regurgitation. Brief Hospital Course: Mr. ___ is a ___ male with a PMH significant for SSS s/p pacemaker placement who presented after an episode of unresponsiveness of unclear etiology, likely not due to a cardiac cause. # Unresponsiveness Patient was having dinner with his wife the day of presentation when he became unresponsive while sitting in the dining room chair. He was reportedly hypotensive, and his wife mentioned that he was yawning during the episode. He became increasingly more alert en route via EMS to ___ ED. While in the ED, he had his pacemaker interrogated and there was no evidence of any arrhythmia or pacemaker malfunction. His pacing rate was increased to 70 beats per minute. He was consistently A-V paced during the entire hospitalization. He was monitored for 48 hours with no further events. Laboratory was only remarkable for a chronic hyponatremia. TTE showed reduced EF with 40% and new moderate-severe aortic stenosis with ___ 1.0 cm2. However, it was felt to be unlikely that his AS was the cause of his episode as he was seated at the time. Ultimately, it was not clear what caused his episode of unresponsiveness, but cardiac etiology thought to be unlikely. # Sick Sinus Syndrome s/p Pacemaker Placement | Paroxysmal Atrial Fibrillation Patient not on anticoagulation due to fall risk and high bleed risk for history of paroxysmal atrial fibrillation. See above for pacemaker interrogation. Digoxin stopped as a nodal blockade agent due to potential difficulty achieving a therapeutic range for the patient and low benefit currently. Patient will discuss replacement agent as an outpatient. # Chronic Aspiration Patient has a history of chronic aspiration and is on a pureed diet at home. He has had prior speech and swallow evaluation with known aspiration risk regardless of any diet type. Speech and Swallow evaluated the patient again this admission and felt that he was not safe for any diet without risk of aspiration. After discussion with his wife and the patient, they choose to pursue eating for comfort, acknowledging the aspiration risks. # Hyponatremia Appears to be chronic based on prior labs. Na flucatuated between low and mid ___. Thyroid function testing revealed moderate hypothyroidism. AM cortisol level was normal. TRANSITIONAL ISSUES - Patient found to be borderline hypothyroid, with high TSH 9.8, and low Free T4 of 0.9 (ref 0.93-1.7). Please consider starting replacement as outpatient. - Digoxin was stopped given low likelihood of benefit. Patient will have follow up with outpatient EP provider, Dr. ___ ___, to further discuss nodal agents for paroxysmal atrial fibrillation. CODE: DNR/DNI per MOLST form Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 4 mg PO DAILY 2. Ipratropium Bromide Neb 1 NEB IH Q8H 3. Docusate Sodium (Liquid) 100 mg PO BID 4. PreserVision AREDS (vitamins A,C,E-zinc-copper) 1 capsule ORAL DAILY 5. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 6. Aspirin 81 mg PO DAILY 7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 8. Digoxin 0.125 mg PO 4X/WEEK (___) 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO BID 11. Senna 8.6 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN itching 14. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 15. Finasteride 5 mg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD DAILY 17. Clindamycin 300 mg PO Q8H 18. Furosemide 10 mg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clindamycin 300 mg PO Q8H 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q8H 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. PredniSONE 4 mg PO DAILY 10. Senna 8.6 mg PO BID 11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 12. Citracal + D (calcium phosphate-vitamin D3) unknown ORAL DAILY 13. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 14. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN itching 15. Furosemide 10 mg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD DAILY 17. PreserVision AREDS (vitamins A,C,E-zinc-copper) 1 capsule ORAL DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: - Syncope - Sick sinus syndrome s/p pacemaker placement - Chronic aspiration and dysphagia - Chronic kidney disease - Aortic stenosis, severe Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you had an episode of loss of consciousness while at home. We performed testing on your pacemaker and performed other studies, and we were unable to determine an exact reason for why you passed out. However, we are not concerned that this is a problem with your heart, and that you are ok to be discharged home for further monitoring. While you were here, we have our swallow specialists evaluate you, and they felt that you are at a high risk for aspirations. However, after discussion with you and your wife, we feel that, it is better for your quality of life to eat rather than worry about aspiration. Because you have heart failure, 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. We have made changes to your medication list, so please make sure to take your medications as directed. You should continue to take the antibiotics, clindamycin, until ___. You will also need to have close follow up with your heart doctor and your primary care doctor. It was a pleasure to take care of you. We wish you the best with your health! Your ___ Cardiac Care Team Followup Instructions: ___
[ "R55", "I959", "I5022", "I712", "I480", "E871", "Z45010", "Z45018", "I447", "I352", "I129", "N183", "N400", "M8580", "H3530", "E038", "G4733", "R2681", "I878", "R251", "Z823", "R1312", "Z66", "Z7982", "Z7952", "R21" ]
Allergies: sulfur dioxide / cephalexin Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with a PMH significant for SSS s/p pacemaker placement who presents after an episode of unresponsiveness while at home yesterday evening. The patient was recently at [MASKED] for a pacemaker generator change after he was found to have low battery life during a routine follow up in clinic. He received no sedation and had an uncomplicated procedure and was discharged home the same day in the afternoon. He was started on clindamycin 800 mg Q8H on discharge. Yesterday evening at home, he was eating dinner with his wife when he suddenly became unresponsive when his wife turned around to get him dessert. He had his eyes open at the time but would not respond to voice or command. His daughter came into the room and checked his pulse, which was noted to be in the [MASKED]. EMS was called and on their arrival, they found his BP to be in the [MASKED]. He became more responsive en route with EMS, and arrived alert to the ED. In the ED initial vitals were: HR 60 BP 106/52 RR 15 SAT 99% RA. The patient was documented to be hypotensive to 81/48 at 21:50 day of arrival. EKG noted by ED staff to be AV paced at 60 BPM with LAD and LBBB. Labs were notable for trop-T of 0.10 then 0.03. Lactate was 1.9. CXR was negative for any acute processes. UA was normal. The patient received 250 mL NS, levofloxacin 750 mg IV, aspirin 324 mg PO, and heparin drip. EP was consulted and interrogated the patient's pacemaker, which was functioning normally. The lower rate was increased to 70 BPM. He was monitored overnight before admission to the floor today. On the floor, he reports feeling well with no specific complaints. He does not remember the events of yesterday. He asked that I speak with his wife for more information. He does not recall having any chest pain, palpitations, dyspnea, cough, fevers, or chills. He does mention that he needs his food pureed at home. Past Medical History: - CHF (EF 45%-50% on TTE [MASKED] - Sick sinus syndrome status post pacemaker placement in [MASKED] at [MASKED] (generator change in [MASKED] due to recurrent syncope, found to have premature battery failure and an elevated RV pacing threshold) - Aortic insufficiency - Aortic stenosis, moderate - Thoracic aortic aneurysm - Paroxysmal supraventricular tachycardia (atrial fibrillation) - Stage 3 CKD - Hypertension - Diverticulosis - Colonic adenoma - Benign prostatic hypertrophy - Osteopenia - Dry macular degeneration - Subclinical hypothyroidism - Obstructive sleep apnea - Unsteady gait with history of syncope and falls - Venous stasis - Tremor Social History: [MASKED] Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 97.8 BP 138/76 HR 70 RR 18 O2 SAT 98% on RA; Wt 74.8 kg by bed scale GENERAL: Frail appearing elderly male in NAD. Oriented to person and time after consulting the wall calendar. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 6-7 cm. CARDIAC: RRR, normal S1, S2. [MASKED] ejection murmur at the bases and no appreciated radiation to the carotids. LUNGS: Respiration is unlabored, no accessory muscle use. Bibasilar inspiratory crackles. ABDOMEN: Soft, nontender, nondistended. No hepatomegaly. EXTREMITIES: Cool distal extremities to touch, trace edema in the lower extremities SKIN: Evidence of venous stasis changes in the lower extremities, some excoriations and throughout the body in particular on the back with various stages of healing PULSES: Radial pulses full bilaterally, 1+ [MASKED] pulses, DP only by Doppler DISCHARGE PHYSICAL EXAMINATION: VS: T afebrile BP 130-139/77 HR 70 RR 16 O2 SAT 95-98% on RA; Wt 73 kg bed scale <-- 74.8 kg by bed scale GENERAL: Frail appearing elderly male in NAD. Mood, affect appropriate. HEENT: NCAT. CARDIAC: RRR, normal S1, S2. [MASKED] ejection murmur at the bases LUNGS: Respiration is unlabored, no accessory muscle use. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Cool distal extremities to touch, trace edema in the lower extremities. SKIN: Evidence of venous stasis changes in the lower extremities, some excoriations and throughout the body in particular on the back with various stages of healing PULSES: 1+ [MASKED] pulses, DP only by Doppler Pertinent Results: ADMISSION LABS ============== [MASKED] 09:19PM [MASKED] PTT-27.5 [MASKED] [MASKED] 09:19PM PLT COUNT-183 [MASKED] 09:19PM NEUTS-65.5 [MASKED] MONOS-7.9 EOS-0.5* BASOS-0.4 IM [MASKED] AbsNeut-5.39 AbsLymp-2.07 AbsMono-0.65 AbsEos-0.04 AbsBaso-0.03 [MASKED] 09:19PM WBC-8.2 RBC-3.80*# HGB-12.4*# HCT-36.7*# MCV-97 MCH-32.6* MCHC-33.8 RDW-13.9 RDWSD-49.4* [MASKED] 09:19PM DIGOXIN-0.5* [MASKED] 09:19PM T4-5.4 T3-73* FREE T4-0.9* [MASKED] 09:19PM TSH-9.8* [MASKED] 09:19PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.0 [MASKED] 09:19PM CK-MB-5 cTropnT-0.10* [MASKED] 09:19PM LIPASE-33 [MASKED] 09:19PM ALT(SGPT)-10 AST(SGOT)-18 CK(CPK)-58 ALK PHOS-108 TOT BILI-0.5 [MASKED] 09:19PM estGFR-Using this [MASKED] 09:19PM GLUCOSE-114* UREA N-23* CREAT-1.2 SODIUM-131* POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-29 ANION GAP-13 [MASKED] 09:20PM LACTATE-1.9 [MASKED] 11:00PM URINE MUCOUS-OCC [MASKED] 11:00PM URINE HYALINE-14* [MASKED] 11:00PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [MASKED] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 11:00PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 11:00PM URINE UHOLD-HOLD [MASKED] 11:00PM URINE OSMOLAL-360 [MASKED] 11:00PM URINE HOURS-RANDOM UREA N-495 CREAT-80 SODIUM-26 POTASSIUM-61 CHLORIDE-38 [MASKED] 08:30AM CK-MB-4 cTropnT-0.03* [MASKED] 08:30AM CK(CPK)-39* [MASKED] 03:30PM MAGNESIUM-2.0 [MASKED] 03:30PM UREA N-21* CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-30 ANION GAP-11 PERTINENT LABS ============== [MASKED] 09:19PM BLOOD Digoxin-0.5* [MASKED] 06:00AM BLOOD Cortsol-9.1 [MASKED] 09:19PM BLOOD T4-5.4 T3-73* Free T4-0.9* [MASKED] 09:19PM BLOOD TSH-9.8* [MASKED] 09:19PM BLOOD CK-MB-5 cTropnT-0.10* [MASKED] 08:30AM BLOOD CK-MB-4 cTropnT-0.03* DISCHARGE LABS ============== [MASKED] 06:00AM BLOOD WBC-6.1 RBC-3.50* Hgb-11.3* Hct-33.3* MCV-95 MCH-32.3* MCHC-33.9 RDW-14.1 RDWSD-48.7* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-84 UreaN-17 Creat-0.8 Na-132* K-3.9 Cl-97 HCO3-27 AnGap-12 [MASKED] 06:00AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8 RADIOLOGY ========= [MASKED] CHEST (PORTABLE AP) FINDINGS: Left-sided pacer device is re- demonstrated with leads terminating in unchanged positions in the right atrium and right ventricle. Severe cardiomegaly is unchanged. The aorta remains tortuous with atherosclerotic calcifications at the knob. Mediastinal and hilar contours are similar. Lungs appear hyperinflated. Linear opacities in the lung bases likely reflect areas of scarring and atelectasis. No focal consolidation, pleural effusion or pneumothorax is detected. IMPRESSION: No acute cardiopulmonary abnormality. CARDIAC STUDIES =============== [MASKED] ECHO Conclusions The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%) secondary to mild global hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate-severe aortic valve stenosis (valve area = 1.0cm2; indexed stroke volume 26 ml/m2; dimensionless index 0.31). Mild-moderate ([MASKED]) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], the degree of calcific aortic stenosis has progressed to moderate-severe (moderate previously). Global left ventricular systolic function is more vigorous. There is slightly less aortic regurgitation. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with a PMH significant for SSS s/p pacemaker placement who presented after an episode of unresponsiveness of unclear etiology, likely not due to a cardiac cause. # Unresponsiveness Patient was having dinner with his wife the day of presentation when he became unresponsive while sitting in the dining room chair. He was reportedly hypotensive, and his wife mentioned that he was yawning during the episode. He became increasingly more alert en route via EMS to [MASKED] ED. While in the ED, he had his pacemaker interrogated and there was no evidence of any arrhythmia or pacemaker malfunction. His pacing rate was increased to 70 beats per minute. He was consistently A-V paced during the entire hospitalization. He was monitored for 48 hours with no further events. Laboratory was only remarkable for a chronic hyponatremia. TTE showed reduced EF with 40% and new moderate-severe aortic stenosis with [MASKED] 1.0 cm2. However, it was felt to be unlikely that his AS was the cause of his episode as he was seated at the time. Ultimately, it was not clear what caused his episode of unresponsiveness, but cardiac etiology thought to be unlikely. # Sick Sinus Syndrome s/p Pacemaker Placement | Paroxysmal Atrial Fibrillation Patient not on anticoagulation due to fall risk and high bleed risk for history of paroxysmal atrial fibrillation. See above for pacemaker interrogation. Digoxin stopped as a nodal blockade agent due to potential difficulty achieving a therapeutic range for the patient and low benefit currently. Patient will discuss replacement agent as an outpatient. # Chronic Aspiration Patient has a history of chronic aspiration and is on a pureed diet at home. He has had prior speech and swallow evaluation with known aspiration risk regardless of any diet type. Speech and Swallow evaluated the patient again this admission and felt that he was not safe for any diet without risk of aspiration. After discussion with his wife and the patient, they choose to pursue eating for comfort, acknowledging the aspiration risks. # Hyponatremia Appears to be chronic based on prior labs. Na flucatuated between low and mid [MASKED]. Thyroid function testing revealed moderate hypothyroidism. AM cortisol level was normal. TRANSITIONAL ISSUES - Patient found to be borderline hypothyroid, with high TSH 9.8, and low Free T4 of 0.9 (ref 0.93-1.7). Please consider starting replacement as outpatient. - Digoxin was stopped given low likelihood of benefit. Patient will have follow up with outpatient EP provider, Dr. [MASKED] [MASKED], to further discuss nodal agents for paroxysmal atrial fibrillation. CODE: DNR/DNI per MOLST form Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 4 mg PO DAILY 2. Ipratropium Bromide Neb 1 NEB IH Q8H 3. Docusate Sodium (Liquid) 100 mg PO BID 4. PreserVision AREDS (vitamins A,C,E-zinc-copper) 1 capsule ORAL DAILY 5. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 6. Aspirin 81 mg PO DAILY 7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 8. Digoxin 0.125 mg PO 4X/WEEK ([MASKED]) 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO BID 11. Senna 8.6 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN itching 14. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 15. Finasteride 5 mg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD DAILY 17. Clindamycin 300 mg PO Q8H 18. Furosemide 10 mg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clindamycin 300 mg PO Q8H 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q8H 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. PredniSONE 4 mg PO DAILY 10. Senna 8.6 mg PO BID 11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 12. Citracal + D (calcium phosphate-vitamin D3) unknown ORAL DAILY 13. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 14. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN itching 15. Furosemide 10 mg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD DAILY 17. PreserVision AREDS (vitamins A,C,E-zinc-copper) 1 capsule ORAL DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: - Syncope - Sick sinus syndrome s/p pacemaker placement - Chronic aspiration and dysphagia - Chronic kidney disease - Aortic stenosis, severe Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you had an episode of loss of consciousness while at home. We performed testing on your pacemaker and performed other studies, and we were unable to determine an exact reason for why you passed out. However, we are not concerned that this is a problem with your heart, and that you are ok to be discharged home for further monitoring. While you were here, we have our swallow specialists evaluate you, and they felt that you are at a high risk for aspirations. However, after discussion with you and your wife, we feel that, it is better for your quality of life to eat rather than worry about aspiration. Because you have heart failure, 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. We have made changes to your medication list, so please make sure to take your medications as directed. You should continue to take the antibiotics, clindamycin, until [MASKED]. You will also need to have close follow up with your heart doctor and your primary care doctor. It was a pleasure to take care of you. We wish you the best with your health! Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED]
[]
[ "I480", "E871", "I129", "N400", "G4733", "Z66" ]
[ "R55: Syncope and collapse", "I959: Hypotension, unspecified", "I5022: Chronic systolic (congestive) heart failure", "I712: Thoracic aortic aneurysm, without rupture", "I480: Paroxysmal atrial fibrillation", "E871: Hypo-osmolality and hyponatremia", "Z45010: Encounter for checking and testing of cardiac pacemaker pulse generator [battery]", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "I447: Left bundle-branch block, unspecified", "I352: Nonrheumatic aortic (valve) stenosis with insufficiency", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M8580: Other specified disorders of bone density and structure, unspecified site", "H3530: Unspecified macular degeneration", "E038: Other specified hypothyroidism", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R2681: Unsteadiness on feet", "I878: Other specified disorders of veins", "R251: Tremor, unspecified", "Z823: Family history of stroke", "R1312: Dysphagia, oropharyngeal phase", "Z66: Do not resuscitate", "Z7982: Long term (current) use of aspirin", "Z7952: Long term (current) use of systemic steroids", "R21: Rash and other nonspecific skin eruption" ]
10,062,617
25,754,091
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sulfur dioxide / cephalexin Attending: ___. Chief Complaint: confusion, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration pneumonia brought to ___ by his family for an episode of transient confusion and lethargy. The patient denies fever, chills, or dysuria, but did have an episode of large volume urinary incontinence on the day of admission. The patient endorsed a lingering cough for 3 weeks, but no acute changes in his breathing. In ED, patient was afebrile with no leukocytosis. There was no reported syncope or focal neurologic deficits, and a NCHCT was negative for stroke. Past Medical History: - Chronic dysphagia, multiple admissions for aspiration pneumonia. On pureed diet at home. Enteral feeding not in line with goals of care. - CHF (EF 45%-50% on TTE ___ - Sick sinus syndrome status post pacemaker placement in ___ at ___ (generator change in ___ due to recurrent syncope, found to have premature battery failure and an elevated RV pacing threshold) - Aortic insufficiency - Aortic stenosis, moderate - Thoracic aortic aneurysm - Paroxysmal atrial fibrillation - Stage 3 CKD - Hypertension - Diverticulosis - Colonic adenoma - Benign prostatic hypertrophy - Osteopenia - Dry macular degeneration - Subclinical hypothyroidism - Obstructive sleep apnea - Unsteady gait with history of syncope and falls - Venous stasis - Tremor Social History: ___ Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 134/73 70 18 97 RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. ___ systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Mild intermittent crackles at right base. No egophony. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN ___ intact. Strength: Left hand grip ___, right ___ otherwise ___ and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, ___ patella 2+ Skin: Erythematous lesion at ___ border of upper lip. DISCHARGE PHYSICAL EXAM: VS: 97.4 113/66 70 18 96% RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. ___ systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Bibasilar crackles. No egophony. Mildly decreased breath sounds on the right. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN ___ intact. Strength: Left hand grip ___, right ___ otherwise ___ and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, ___ patella 2+ Skin: Erythematous lesion at ___ border of upper lip. Pertinent Results: ADMISSION LABS ================================== ___:01PM BLOOD WBC-10.9*# RBC-3.69* Hgb-11.5* Hct-33.6* MCV-91 MCH-31.2 MCHC-34.2 RDW-13.3 RDWSD-44.3 Plt ___ ___ 09:01PM BLOOD Neuts-79.5* Lymphs-14.9* Monos-4.8* Eos-0.2* Baso-0.1 Im ___ AbsNeut-8.67*# AbsLymp-1.63 AbsMono-0.52 AbsEos-0.02* AbsBaso-0.01 ___ 09:01PM BLOOD ___ PTT-26.9 ___ ___ 09:01PM BLOOD Glucose-103* UreaN-28* Creat-1.2 Na-128* K-4.4 Cl-91* HCO3-24 AnGap-17 ___ 09:01PM BLOOD ___ 09:01PM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 ___ 09:37PM BLOOD Lactate-1.3 DISCHARGE LABS ================================== ___ 05:53AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.8* Hct-30.6* MCV-92 MCH-32.4* MCHC-35.3 RDW-13.7 RDWSD-46.0 Plt ___ ___ 05:53AM BLOOD Glucose-99 UreaN-23* Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 ___ 05:53AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0 MICRO ================================== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ Blood Culture, Routine-PENDING ___ Blood Culture, Routine-PENDING STUDIES =================================== ECG ___: Atrioventricular sequential pacing. Compared to the previous tracing of ___ findings are similar. CXR ___: Limited assessment of the lung apices. Patchy opacities in the right lung base may reflect infection or aspiration in the correct clinical setting. Streaky retrocardiac atelectasis. CXR ___: Comparison to ___. Mild pulmonary edema is present on today's examination. New right basal parenchymal opacity, potentially reflecting aspiration. Stable appearance of the cardiac silhouette. Non-contrast CT Head ___: 1. Evaluation is mildly limited by motion. 2. No CT evidence of acute intracranial process. MRI would be more sensitive for evaluation of ischemia. 3. Nonspecific left periventricular white matter lesion stable from ___, may represent a cavernoma. 4. Sinus disease, possible acute right maxillary sinusitis. Brief Hospital Course: Mr. ___ is a ___ with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration brought to ___ by family for transient confusion and lethargy, found to have aspiration pneumonia. ACTIVE ISSUES ========================== # Community acquired pneumonia / food aspiration Patient with several years of dysphagia (on pureed diet with nectar-thick liquids at home) and multiple hospitalizations for aspiration pneumonia. Found to have leukocytosis to 12.8, low-grade fever to 99.8, and evolving RLL opacities on CXRs consistent with aspiration pneumonia. He was treated with levofloxacin 750mg q48 x 5 days (renal dosing, ___ allergic to cephalosporins). He remained hemodynamically stable on room air throughout admission, and fever and leukocytosis resolved with abx. Home pureed diet and aspiration precautions were continued (enteral feeding not consistent with patient's goals of care). # Toxic-metabolic encephalopathy Waxing/waning alertness and attention consistent with hypoactive delirium. Likely secondary to PNA. UA clean and bladder scans negative for retention. No focal deficits and NCHCT negative for stroke. Recent pacer interrogation negative for arrhythmia/dysfunction. Patient continued to have waxing/waning but was discharged at baseline per family. # Acute on chronic renal failure Prerenal ___ resolved with 500cc NS. No evidence for obstruction on exam or bladder scans. # Benign prostatic hyperplasia Patient had large volume urinary incontinence on day of admission and intermittent obstructive symptoms. However, no suprapubic tenderness on exam or retention on bladder scans. Home finasteride was continued. # Acute on chronic hyponatremia Baseline Na 128-130s. Na 128 on admission, improved to 131 with 500cc NS in ED. # Chronic systolic heart failure TTE ___ with EF 30%, moderate-severe AS, mild-moderate AR. No evidence for exacerbation on exam; proBNP ___, stable from ___. Continued home Lasix. # Sick sinus syndrome status post pacemaker Recent interrogation in ___ with no evidence of pacer dysfunction. Repeat interrogation was not done given lack of presyncope, palpitations, or arrhythmias on ECG or tele. CHRONIC ISSUES ============================== # Dermatitis: followed by Dermatology at ___. Continued home prednisone and topical steroids. # GERD: well controlled, continued home PPI. # Hypothyroidism: no acute symptoms, continued home synthroid. TRANSITIONAL ISSUES =============================== - CAP/aspiration: treated with levofloxacin 750mg q48h x 5 days (renal dosing, last day ___ - Aspiration: no safe diet per SpSw but enteral feeding not consistent with patient's goals of care. Advised to continue prior pureed diet and precautions. - Discharge weight: 72.8 kg - Discharge diuretic: furosemide 20 mg # CONTACT: ___ (wife) ___ # CODE: DNR/DNI (MOLST form from ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Community acquired pneumonia Toxic-metabolic encephalopathy SECONDARY DIAGNOSES Acute on chronic renal failure Chronic systolic heart failure Sick sinus syndrome status post pacemaker placement Chronic hyponatremia Benign prostatic hypertrophy Hypothyroidism Gastrointestinal reflux disease Dermatitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to ___ for pneumonia. The infection was likely caused by some food that went into your lung. We gave you antibiotics and you improved. Instructions for when you leave the hospital: - Continue to take all of your home medications. - Continue your pureed diet. Take small slow bites. Sit upright while eating. - Call your doctor or return to the hospital if you feel any confusion, shortness of breath, chest pain, fevers, chills, or any other symptoms that concern you. It was a pleasure taking care of you! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "J690", "G92", "N179", "R1310", "E871", "I130", "I5022", "Z950", "I352", "Z23", "N401", "N39498", "L309", "K219", "E039", "Z66", "N183" ]
Allergies: sulfur dioxide / cephalexin Chief Complaint: confusion, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration pneumonia brought to [MASKED] by his family for an episode of transient confusion and lethargy. The patient denies fever, chills, or dysuria, but did have an episode of large volume urinary incontinence on the day of admission. The patient endorsed a lingering cough for 3 weeks, but no acute changes in his breathing. In ED, patient was afebrile with no leukocytosis. There was no reported syncope or focal neurologic deficits, and a NCHCT was negative for stroke. Past Medical History: - Chronic dysphagia, multiple admissions for aspiration pneumonia. On pureed diet at home. Enteral feeding not in line with goals of care. - CHF (EF 45%-50% on TTE [MASKED] - Sick sinus syndrome status post pacemaker placement in [MASKED] at [MASKED] (generator change in [MASKED] due to recurrent syncope, found to have premature battery failure and an elevated RV pacing threshold) - Aortic insufficiency - Aortic stenosis, moderate - Thoracic aortic aneurysm - Paroxysmal atrial fibrillation - Stage 3 CKD - Hypertension - Diverticulosis - Colonic adenoma - Benign prostatic hypertrophy - Osteopenia - Dry macular degeneration - Subclinical hypothyroidism - Obstructive sleep apnea - Unsteady gait with history of syncope and falls - Venous stasis - Tremor Social History: [MASKED] Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 134/73 70 18 97 RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. [MASKED] systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Mild intermittent crackles at right base. No egophony. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN [MASKED] intact. Strength: Left hand grip [MASKED], right [MASKED] otherwise [MASKED] and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, [MASKED] patella 2+ Skin: Erythematous lesion at [MASKED] border of upper lip. DISCHARGE PHYSICAL EXAM: VS: 97.4 113/66 70 18 96% RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. [MASKED] systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Bibasilar crackles. No egophony. Mildly decreased breath sounds on the right. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN [MASKED] intact. Strength: Left hand grip [MASKED], right [MASKED] otherwise [MASKED] and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, [MASKED] patella 2+ Skin: Erythematous lesion at [MASKED] border of upper lip. Pertinent Results: ADMISSION LABS ================================== [MASKED]:01PM BLOOD WBC-10.9*# RBC-3.69* Hgb-11.5* Hct-33.6* MCV-91 MCH-31.2 MCHC-34.2 RDW-13.3 RDWSD-44.3 Plt [MASKED] [MASKED] 09:01PM BLOOD Neuts-79.5* Lymphs-14.9* Monos-4.8* Eos-0.2* Baso-0.1 Im [MASKED] AbsNeut-8.67*# AbsLymp-1.63 AbsMono-0.52 AbsEos-0.02* AbsBaso-0.01 [MASKED] 09:01PM BLOOD [MASKED] PTT-26.9 [MASKED] [MASKED] 09:01PM BLOOD Glucose-103* UreaN-28* Creat-1.2 Na-128* K-4.4 Cl-91* HCO3-24 AnGap-17 [MASKED] 09:01PM BLOOD [MASKED] 09:01PM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 [MASKED] 09:37PM BLOOD Lactate-1.3 DISCHARGE LABS ================================== [MASKED] 05:53AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.8* Hct-30.6* MCV-92 MCH-32.4* MCHC-35.3 RDW-13.7 RDWSD-46.0 Plt [MASKED] [MASKED] 05:53AM BLOOD Glucose-99 UreaN-23* Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 [MASKED] 05:53AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0 MICRO ================================== URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. [MASKED] Blood Culture, Routine-PENDING [MASKED] Blood Culture, Routine-PENDING STUDIES =================================== ECG [MASKED]: Atrioventricular sequential pacing. Compared to the previous tracing of [MASKED] findings are similar. CXR [MASKED]: Limited assessment of the lung apices. Patchy opacities in the right lung base may reflect infection or aspiration in the correct clinical setting. Streaky retrocardiac atelectasis. CXR [MASKED]: Comparison to [MASKED]. Mild pulmonary edema is present on today's examination. New right basal parenchymal opacity, potentially reflecting aspiration. Stable appearance of the cardiac silhouette. Non-contrast CT Head [MASKED]: 1. Evaluation is mildly limited by motion. 2. No CT evidence of acute intracranial process. MRI would be more sensitive for evaluation of ischemia. 3. Nonspecific left periventricular white matter lesion stable from [MASKED], may represent a cavernoma. 4. Sinus disease, possible acute right maxillary sinusitis. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration brought to [MASKED] by family for transient confusion and lethargy, found to have aspiration pneumonia. ACTIVE ISSUES ========================== # Community acquired pneumonia / food aspiration Patient with several years of dysphagia (on pureed diet with nectar-thick liquids at home) and multiple hospitalizations for aspiration pneumonia. Found to have leukocytosis to 12.8, low-grade fever to 99.8, and evolving RLL opacities on CXRs consistent with aspiration pneumonia. He was treated with levofloxacin 750mg q48 x 5 days (renal dosing, [MASKED] allergic to cephalosporins). He remained hemodynamically stable on room air throughout admission, and fever and leukocytosis resolved with abx. Home pureed diet and aspiration precautions were continued (enteral feeding not consistent with patient's goals of care). # Toxic-metabolic encephalopathy Waxing/waning alertness and attention consistent with hypoactive delirium. Likely secondary to PNA. UA clean and bladder scans negative for retention. No focal deficits and NCHCT negative for stroke. Recent pacer interrogation negative for arrhythmia/dysfunction. Patient continued to have waxing/waning but was discharged at baseline per family. # Acute on chronic renal failure Prerenal [MASKED] resolved with 500cc NS. No evidence for obstruction on exam or bladder scans. # Benign prostatic hyperplasia Patient had large volume urinary incontinence on day of admission and intermittent obstructive symptoms. However, no suprapubic tenderness on exam or retention on bladder scans. Home finasteride was continued. # Acute on chronic hyponatremia Baseline Na 128-130s. Na 128 on admission, improved to 131 with 500cc NS in ED. # Chronic systolic heart failure TTE [MASKED] with EF 30%, moderate-severe AS, mild-moderate AR. No evidence for exacerbation on exam; proBNP [MASKED], stable from [MASKED]. Continued home Lasix. # Sick sinus syndrome status post pacemaker Recent interrogation in [MASKED] with no evidence of pacer dysfunction. Repeat interrogation was not done given lack of presyncope, palpitations, or arrhythmias on ECG or tele. CHRONIC ISSUES ============================== # Dermatitis: followed by Dermatology at [MASKED]. Continued home prednisone and topical steroids. # GERD: well controlled, continued home PPI. # Hypothyroidism: no acute symptoms, continued home synthroid. TRANSITIONAL ISSUES =============================== - CAP/aspiration: treated with levofloxacin 750mg q48h x 5 days (renal dosing, last day [MASKED] - Aspiration: no safe diet per SpSw but enteral feeding not consistent with patient's goals of care. Advised to continue prior pureed diet and precautions. - Discharge weight: 72.8 kg - Discharge diuretic: furosemide 20 mg # CONTACT: [MASKED] (wife) [MASKED] # CODE: DNR/DNI (MOLST form from [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES Community acquired pneumonia Toxic-metabolic encephalopathy SECONDARY DIAGNOSES Acute on chronic renal failure Chronic systolic heart failure Sick sinus syndrome status post pacemaker placement Chronic hyponatremia Benign prostatic hypertrophy Hypothyroidism Gastrointestinal reflux disease Dermatitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] for pneumonia. The infection was likely caused by some food that went into your lung. We gave you antibiotics and you improved. Instructions for when you leave the hospital: - Continue to take all of your home medications. - Continue your pureed diet. Take small slow bites. Sit upright while eating. - Call your doctor or return to the hospital if you feel any confusion, shortness of breath, chest pain, fevers, chills, or any other symptoms that concern you. It was a pleasure taking care of you! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "E871", "I130", "K219", "E039", "Z66" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "R1310: Dysphagia, unspecified", "E871: Hypo-osmolality and hyponatremia", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "Z950: Presence of cardiac pacemaker", "I352: Nonrheumatic aortic (valve) stenosis with insufficiency", "Z23: Encounter for immunization", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "N39498: Other specified urinary incontinence", "L309: Dermatitis, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E039: Hypothyroidism, unspecified", "Z66: Do not resuscitate", "N183: Chronic kidney disease, stage 3 (moderate)" ]
10,062,617
28,840,277
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sulfur dioxide Attending: ___. Chief Complaint: Malaise/Fatigue with 2 recent falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old male with history of HFrEF (EF 25%-30% on TTE ___, sick sinus syndrome s/p pacemaker, paroxysmal supraventricular tachycardia, and chronic dermatitis on low-dose oral steroid who presents for malaise in the setting of two recent falls. At baseline, patient is able to ambulate with a cane and with the help of his wife. Has aide to assist with activities of daily living. Patient reports being in his usual state of health until he fell two weeks prior from losing his grip on the refrigerator door. Three days ago, had mechanical fall due to missed handle grip on walking down stairs, falling backwards onto lower back with headstrike and possible LOC. Prior to these two episodes, did not have falls since ___. Patient presented to ___ ED on ___ ___nd an episode of worsening bilateral arm tremor. Head CT was negative for intracranial bleed and patient was discharged to home. Patient woke up this morning with temperature of 99.4 measured at home and generalized weakness. Has chronic intermittent cough for past few months. No nausea/vomiting, diarrhea, chest pain. No sick contacts, recent travels. No episode of swallowing with coughing fit although patient has dysphagia at baseline. In the ED, initial vitals: 100.2 60 88/51 16 94%RA Labs were significant for WBC 9.6 (77.9N) Hgb 10.5 Na 128 GFR 62 BUN 23 Cr 1.1 Imaging showed new opacity at the right medial lung base concerning for pneumonia In the ED, he received 1g Tylenol, 1L NS, and vanc/zosyn. Vitals prior to transfer: 98.2 61 104/53 15 96%RA On arrival to the floor, patient was feeling well and asymptomatic except for mild, chronic, intermittent, non-productive cough. Past Medical History: HFrEF (EF 25%-30% on TTE ___ Sick sinus syndrome status post pacemaker placement h/o pacemaker lead failure Aortic insufficiency Thoracic aortic aneurysm Paroxysmal supraventricular tachycardia Hypertension Diverticulosis Colonic adenoma Benign prostatic hypertrophy Osteopenia Dry macular degeneration Subclinical hypothyroidism Obstructive sleep apnea Unsteady gait with h/o syncope and falls Stage 3 CKD Venous stasis Tremor Social History: ___ Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4 104/52 65 17 98%RA GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Generally CTA b/l with dullness at the R base COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: A&O x3 (name, hospital, month and day), CN II-XII grossly intact, motor function grossly normal, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention DISCHARGE PHYSICAL EXAM: Vitals: 98.8 98.8 104/58 59 18 94%RA 111/47 -> 109/47 (lying down to sitting) GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Rhonchi at bases bilaterally COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended, +BS GU: no foley EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: AOx3, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention Pertinent Results: On admission: ___ 07:30AM BLOOD WBC-9.6# RBC-3.13* Hgb-10.5* Hct-30.2* MCV-97 MCH-33.5* MCHC-34.8 RDW-13.5 RDWSD-47.5* Plt ___ ___ 07:30AM BLOOD Neuts-77.9* Lymphs-15.6* Monos-5.8 Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.48* AbsLymp-1.50 AbsMono-0.56 AbsEos-0.01* AbsBaso-0.02 ___ 07:30AM BLOOD ___ PTT-26.9 ___ ___ 07:30AM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-128* K-4.9 Cl-93* HCO3-26 AnGap-14 ___ 07:30AM BLOOD ALT-15 AST-20 AlkPhos-114 TotBili-1.4 ___ 07:30AM BLOOD cTropnT-0.02* ___ 07:30AM BLOOD proBNP-699 ___ 07:30AM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.1 Mg-1.9 ___ 07:30AM BLOOD Osmolal-265* ___ 07:30AM BLOOD Digoxin-0.6* ___ 07:44AM BLOOD Lactate-1.8 ___ 08:12AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:12AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 08:12AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 ___ 08:12AM URINE Mucous-RARE ___ 08:40AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE In the interim: ___ 06:40AM BLOOD WBC-5.2 RBC-2.95* Hgb-9.7* Hct-29.4* MCV-100* MCH-32.9* MCHC-33.0 RDW-13.5 RDWSD-49.0* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-132* K-3.9 Cl-100 HCO3-24 AnGap-12 ___ 06:40AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 ___ 03:00PM URINE Hours-RANDOM Creat-68 Na-80 K-59 Cl-74 ___ 03:00PM URINE Osmolal-443 On discharge: ___ 09:11AM BLOOD WBC-6.2 RBC-2.91* Hgb-9.6* Hct-28.7* MCV-99* MCH-33.0* MCHC-33.4 RDW-13.4 RDWSD-48.8* Plt ___ ___ 09:11AM BLOOD Plt ___ ___ 09:11AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-132* K-3.7 Cl-100 HCO3-24 AnGap-12 Microbiology: Blood cx ___ x2): No growth to date Urine cx (___): Mixed bacterial flora (>=3 colony types), consistent with fecal contamination Imaging: CXR (___): New opacity at the right medial lung base is concerning for pneumonia Brief Hospital Course: Mr. ___ is a ___ year-old male with history of HFrEF (EF 25%-30% on TTE ___, chronic dysphagia with aspiration, sick sinus syndrome s/p pacemaker, and dermatitis on chronic ___ oral prednisone presenting with weakness/lethargy in the setting of ___nd found to have RML consolidation on CXR concerning for CAP vs aspiration pneumonia treated with 5 day course of Levaquin 750mg. #Malaise and opacity on CXR: Patient presented with malaise and CXR concerning for consolidation. Most likely etiology was CAP (no recent inpatient admission, no exposure to SNF/LTAC/HD) vs aspiration (history of dysphagia). Patient was given IV vanc/zosyn in the ED and transitioned to PO levofloxacin 750mg daily with plans for course of 5 days (last dose ___. During hospitalization, patient remained afebrile with no leukocytosis and was hemodynamically stable. Patient was discharged on ___ to rehab to complete levofloxacin course. # Compensated HFrEF: The patient has HFrEF (EF ___. BNP was not elevated and patient remained euvolemic on exam, without ___ edema, JVP elevation or hypoxia. Digoxin 125mcg ___ was continued. Discharge weight 164 pounds per bed weight. # Hyponatremia: Patient presented with sodium 128 that was below baseline 130-135. On HD2, hyponatremia improved to 132 with good POs. No mental status changes. No recent vomiting/diarrhea. Not on diuretics. Most likely caused by poor PO intake. # Falls: Two recent mechanical falls. Previous fall in ___. Head CT at ___ on ___ negative for intracranial bleed. ___ evaluation recommended rehab. CHRONIC ISSUES: # Tremor: Patient has chronic resting tremor high frequency, low amplitude resting tremor on R forearm which extinguishes with intention. Given patient's long history of resting tremor, may consider outpatient neurology evaluation. # Dysphagia: SLP recommended nectar thick and soft solids with recognition of aspiration with any PO intake. # Sick sinus syndrome s/p pacemaker: recently checked in ___. No device issues noted. # Chronic normocytic anemia: Patient has hct of ___ at baseline. No melena or hematochezia. Patient did not have evidence of active bleeding and hct remained stable during hospitalization. # CKD stage 3: Cr continued to be 0.9-1.1 at baseline. Levofloxacin dosed q48hrs per renal dosing. TRANSITIONAL ISSUES: - Levofloxacin course to end ___ - Consider outpatient Neurology consultation for dysphagia, weakness, tremulousness and recurrent falls - Code: DNR, okay to intubate per MOLST - Contact: ___, wife/HCP, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Digoxin 0.125 mg PO 4X/WEEK (___) 3. Docusate Sodium 100-200 mg PO BID 4. Ipratropium Bromide Neb 1 NEB IH Q8H 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Senna 8.6 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 10. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 11. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 13. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 14. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 15. permethrin 5 % topical QPM infection 16. PredniSONE 5 mg PO DAILY Tapered dose - DOWN Discharge Medications: 1. Levofloxacin 750 mg PO Q48H Duration: 4 Days Take one more dose on ___ to complete a ___. PredniSONE 5 mg PO DAILY 3. Ipratropium Bromide Neb 1 NEB IH Q8H 4. Docusate Sodium (Liquid) 100 mg PO BID 5. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 6. permethrin 5 % topical QPM infection 7. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 8. Aspirin 81 mg PO DAILY 9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 10. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 11. Digoxin 0.125 mg PO 4X/WEEK (___) 12. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 16. Senna 8.6 mg PO BID 17. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Pneumonia Secondary: Falls, compensated heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___: You were recently admitted to ___ for pneumonia. We started you on an antibiotic called Levofloxacin (Levaquin) which you should take on ___ to complete your treatment. Because you have been falling recently, we asked our physical therapist to evaluate you and they recommended that you be discharged to rehabilitation ___ to work on your strength and balance. Please take your medications as prescribed and follow up with your physicians as below. We wish you the best, Your ___ care team Followup Instructions: ___
[ "J690", "I5022", "I471", "E871", "R1310", "I712", "I129", "N183", "Z9181", "G4733", "R251", "D649", "Z950", "L309", "Z7952", "Z66" ]
Allergies: sulfur dioxide Chief Complaint: Malaise/Fatigue with 2 recent falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year-old male with history of HFrEF (EF 25%-30% on TTE [MASKED], sick sinus syndrome s/p pacemaker, paroxysmal supraventricular tachycardia, and chronic dermatitis on low-dose oral steroid who presents for malaise in the setting of two recent falls. At baseline, patient is able to ambulate with a cane and with the help of his wife. Has aide to assist with activities of daily living. Patient reports being in his usual state of health until he fell two weeks prior from losing his grip on the refrigerator door. Three days ago, had mechanical fall due to missed handle grip on walking down stairs, falling backwards onto lower back with headstrike and possible LOC. Prior to these two episodes, did not have falls since [MASKED]. Patient presented to [MASKED] ED on [MASKED] nd an episode of worsening bilateral arm tremor. Head CT was negative for intracranial bleed and patient was discharged to home. Patient woke up this morning with temperature of 99.4 measured at home and generalized weakness. Has chronic intermittent cough for past few months. No nausea/vomiting, diarrhea, chest pain. No sick contacts, recent travels. No episode of swallowing with coughing fit although patient has dysphagia at baseline. In the ED, initial vitals: 100.2 60 88/51 16 94%RA Labs were significant for WBC 9.6 (77.9N) Hgb 10.5 Na 128 GFR 62 BUN 23 Cr 1.1 Imaging showed new opacity at the right medial lung base concerning for pneumonia In the ED, he received 1g Tylenol, 1L NS, and vanc/zosyn. Vitals prior to transfer: 98.2 61 104/53 15 96%RA On arrival to the floor, patient was feeling well and asymptomatic except for mild, chronic, intermittent, non-productive cough. Past Medical History: HFrEF (EF 25%-30% on TTE [MASKED] Sick sinus syndrome status post pacemaker placement h/o pacemaker lead failure Aortic insufficiency Thoracic aortic aneurysm Paroxysmal supraventricular tachycardia Hypertension Diverticulosis Colonic adenoma Benign prostatic hypertrophy Osteopenia Dry macular degeneration Subclinical hypothyroidism Obstructive sleep apnea Unsteady gait with h/o syncope and falls Stage 3 CKD Venous stasis Tremor Social History: [MASKED] Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4 104/52 65 17 98%RA GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Generally CTA b/l with dullness at the R base COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: A&O x3 (name, hospital, month and day), CN II-XII grossly intact, motor function grossly normal, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention DISCHARGE PHYSICAL EXAM: Vitals: 98.8 98.8 104/58 59 18 94%RA 111/47 -> 109/47 (lying down to sitting) GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Rhonchi at bases bilaterally COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended, +BS GU: no foley EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: AOx3, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention Pertinent Results: On admission: [MASKED] 07:30AM BLOOD WBC-9.6# RBC-3.13* Hgb-10.5* Hct-30.2* MCV-97 MCH-33.5* MCHC-34.8 RDW-13.5 RDWSD-47.5* Plt [MASKED] [MASKED] 07:30AM BLOOD Neuts-77.9* Lymphs-15.6* Monos-5.8 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-7.48* AbsLymp-1.50 AbsMono-0.56 AbsEos-0.01* AbsBaso-0.02 [MASKED] 07:30AM BLOOD [MASKED] PTT-26.9 [MASKED] [MASKED] 07:30AM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-128* K-4.9 Cl-93* HCO3-26 AnGap-14 [MASKED] 07:30AM BLOOD ALT-15 AST-20 AlkPhos-114 TotBili-1.4 [MASKED] 07:30AM BLOOD cTropnT-0.02* [MASKED] 07:30AM BLOOD proBNP-699 [MASKED] 07:30AM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.1 Mg-1.9 [MASKED] 07:30AM BLOOD Osmolal-265* [MASKED] 07:30AM BLOOD Digoxin-0.6* [MASKED] 07:44AM BLOOD Lactate-1.8 [MASKED] 08:12AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 08:12AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [MASKED] 08:12AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [MASKED] 08:12AM URINE Mucous-RARE [MASKED] 08:40AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE In the interim: [MASKED] 06:40AM BLOOD WBC-5.2 RBC-2.95* Hgb-9.7* Hct-29.4* MCV-100* MCH-32.9* MCHC-33.0 RDW-13.5 RDWSD-49.0* Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-132* K-3.9 Cl-100 HCO3-24 AnGap-12 [MASKED] 06:40AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 [MASKED] 03:00PM URINE Hours-RANDOM Creat-68 Na-80 K-59 Cl-74 [MASKED] 03:00PM URINE Osmolal-443 On discharge: [MASKED] 09:11AM BLOOD WBC-6.2 RBC-2.91* Hgb-9.6* Hct-28.7* MCV-99* MCH-33.0* MCHC-33.4 RDW-13.4 RDWSD-48.8* Plt [MASKED] [MASKED] 09:11AM BLOOD Plt [MASKED] [MASKED] 09:11AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-132* K-3.7 Cl-100 HCO3-24 AnGap-12 Microbiology: Blood cx [MASKED] x2): No growth to date Urine cx ([MASKED]): Mixed bacterial flora (>=3 colony types), consistent with fecal contamination Imaging: CXR ([MASKED]): New opacity at the right medial lung base is concerning for pneumonia Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old male with history of HFrEF (EF 25%-30% on TTE [MASKED], chronic dysphagia with aspiration, sick sinus syndrome s/p pacemaker, and dermatitis on chronic [MASKED] oral prednisone presenting with weakness/lethargy in the setting of nd found to have RML consolidation on CXR concerning for CAP vs aspiration pneumonia treated with 5 day course of Levaquin 750mg. #Malaise and opacity on CXR: Patient presented with malaise and CXR concerning for consolidation. Most likely etiology was CAP (no recent inpatient admission, no exposure to SNF/LTAC/HD) vs aspiration (history of dysphagia). Patient was given IV vanc/zosyn in the ED and transitioned to PO levofloxacin 750mg daily with plans for course of 5 days (last dose [MASKED]. During hospitalization, patient remained afebrile with no leukocytosis and was hemodynamically stable. Patient was discharged on [MASKED] to rehab to complete levofloxacin course. # Compensated HFrEF: The patient has HFrEF (EF [MASKED]. BNP was not elevated and patient remained euvolemic on exam, without [MASKED] edema, JVP elevation or hypoxia. Digoxin 125mcg [MASKED] was continued. Discharge weight 164 pounds per bed weight. # Hyponatremia: Patient presented with sodium 128 that was below baseline 130-135. On HD2, hyponatremia improved to 132 with good POs. No mental status changes. No recent vomiting/diarrhea. Not on diuretics. Most likely caused by poor PO intake. # Falls: Two recent mechanical falls. Previous fall in [MASKED]. Head CT at [MASKED] on [MASKED] negative for intracranial bleed. [MASKED] evaluation recommended rehab. CHRONIC ISSUES: # Tremor: Patient has chronic resting tremor high frequency, low amplitude resting tremor on R forearm which extinguishes with intention. Given patient's long history of resting tremor, may consider outpatient neurology evaluation. # Dysphagia: SLP recommended nectar thick and soft solids with recognition of aspiration with any PO intake. # Sick sinus syndrome s/p pacemaker: recently checked in [MASKED]. No device issues noted. # Chronic normocytic anemia: Patient has hct of [MASKED] at baseline. No melena or hematochezia. Patient did not have evidence of active bleeding and hct remained stable during hospitalization. # CKD stage 3: Cr continued to be 0.9-1.1 at baseline. Levofloxacin dosed q48hrs per renal dosing. TRANSITIONAL ISSUES: - Levofloxacin course to end [MASKED] - Consider outpatient Neurology consultation for dysphagia, weakness, tremulousness and recurrent falls - Code: DNR, okay to intubate per MOLST - Contact: [MASKED], wife/HCP, [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Digoxin 0.125 mg PO 4X/WEEK ([MASKED]) 3. Docusate Sodium 100-200 mg PO BID 4. Ipratropium Bromide Neb 1 NEB IH Q8H 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Senna 8.6 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 10. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 11. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 13. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 14. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 15. permethrin 5 % topical QPM infection 16. PredniSONE 5 mg PO DAILY Tapered dose - DOWN Discharge Medications: 1. Levofloxacin 750 mg PO Q48H Duration: 4 Days Take one more dose on [MASKED] to complete a [MASKED]. PredniSONE 5 mg PO DAILY 3. Ipratropium Bromide Neb 1 NEB IH Q8H 4. Docusate Sodium (Liquid) 100 mg PO BID 5. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 6. permethrin 5 % topical QPM infection 7. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 8. Aspirin 81 mg PO DAILY 9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 10. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 11. Digoxin 0.125 mg PO 4X/WEEK ([MASKED]) 12. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 16. Senna 8.6 mg PO BID 17. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Pneumonia Secondary: Falls, compensated heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED]: You were recently admitted to [MASKED] for pneumonia. We started you on an antibiotic called Levofloxacin (Levaquin) which you should take on [MASKED] to complete your treatment. Because you have been falling recently, we asked our physical therapist to evaluate you and they recommended that you be discharged to rehabilitation [MASKED] to work on your strength and balance. Please take your medications as prescribed and follow up with your physicians as below. We wish you the best, Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "E871", "I129", "G4733", "D649", "Z66" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "I5022: Chronic systolic (congestive) heart failure", "I471: Supraventricular tachycardia", "E871: Hypo-osmolality and hyponatremia", "R1310: Dysphagia, unspecified", "I712: Thoracic aortic aneurysm, without rupture", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z9181: History of falling", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R251: Tremor, unspecified", "D649: Anemia, unspecified", "Z950: Presence of cardiac pacemaker", "L309: Dermatitis, unspecified", "Z7952: Long term (current) use of systemic steroids", "Z66: Do not resuscitate" ]
10,062,931
25,070,309
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Sulfa(Sulfonamide Antibiotics) / Lyrica Attending: ___. Chief Complaint: parkinsons disease Major Surgical or Invasive Procedure: right DBS lead placement and removal Dr ___ on ___ History of Present Illness: This iis aa ___ year old male who presents today electivey for right sided DBS stage 1&2 Past Medical History: ___ disease atrial fibrillation s/p ablation three-vessel coronary artery bypass graft in ___ dyslipidemia ischemic heart disease stent intention tremor myocardial infarction ___ reflus Social History: ___ Family History: Family history is significant for ___ disease in the patient's mother. Physical Exam: ___: bilateral tremors in all four extremities noted. alert and oriented to person/place/time strength is full no pronator drift EOM intact face symmetric pupils ___ bilaterally Brief Hospital Course: This is a ___ year old male with ___ Disease and s/p left sided DBS who presents electively for a right sided DBS stage 1 and 2 today. The patients pre existing left sided DBS was turned off prior to his pre operative MRI. The patient was taken to the OR and tolerated the procedure well. The post operative imaging was consistent with improper lead positioning. The patient was taken back to the OR for lead removal. The patient left the OR and did not have any right sided DBS hardware in place. The patient was recovered in the PACU. The patient preexisting left sided DBS was turned back on by the ___ representative in the PACU. When the patient was fully recovered from anesthesia they were transferred to the neurosurgery floor. The patients diet was advanced and was able to ambulate. On POD1 he remained stable and was discharged home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amantadine 100 mg PO ___ TIMES A DAY: PRN parkinsons 2. Carbidopa-Levodopa (___) 1 TAB PO QID 3. Lodosyn (carbidopa) 25 mg oral ___ times a day parkinsons disease 4. Carvedilol 3.125 mg PO Q AM 5. Celebrex ___ mg oral Q24H 6. Duloxetine 60 mg PO DAILY 7. Enalapril Maleate 5 mg PO QD:PRN for sbp >140 8. Lorazepam 1 mg PO QD PRN anxiety 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN pain 10. Simvastatin 10 mg PO QPM 11. Aspirin 81 mg PO DAILY 12. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 300mg-300mg oral qd 13. Fish Oil (Omega 3) Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Do not exceed 4G of acetaminophen in a 24 hour period. 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. Codeine Sulfate ___ mg PO Q4H:PRN headache RX *codeine sulfate 15 mg ___ tablet(s) by mouth prn Disp #*20 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Senna 17.2 mg PO HS 7. Carbidopa-Levodopa (___) 1 TAB PO TID 8. Carbidopa-Levodopa (___) 1.5 TAB PO QAM 9. Carbidopa-Levodopa CR (___) 1 TAB PO QHS 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. Amantadine 100 mg PO ___ TIMES A DAY: PRN parkinsons 12. Aspirin 81 mg PO DAILY ** you may begin retaking on ___. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 300mg-300mg oral qd 14. Carbidopa-Levodopa (___) 1 TAB PO QID 15. Carvedilol 3.125 mg PO Q AM 16. Celecoxib 200 mg ORAL Q24H ** you may begin retaking on ___. Duloxetine 60 mg PO DAILY 18. Enalapril Maleate 5 mg PO QD:PRN for sbp >140 19. Lodosyn (carbidopa) 25 mg oral ___ times a day parkinsons disease 20. Lorazepam 1 mg PO QD PRN anxiety 21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN pain 22. Simvastatin 10 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ___ disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ ___ Brain ___ Surgery · You underwent Stage I of the DBS on the right side, however, the lead had to be removed. You will need to contact Dr. ___ office to schedule another surgery for right sided stages I and II. Activity · You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. · You may take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much too soon. · Do not go swimming or submerge yourself in water for fourteen (14) days after your procedure. · The dressing covering your head incision(s) may be removed after 48 hours. You may use a damp washcloth to remove any dried blood or iodine from your skin but do not get your head wet in the shower until your staples or sutures are removed. Medications · Resume your normal ___ medications. The neurologist programming your device may adjust your medications once programming begins. · Take any new medications (i.e. pain medications) as directed. · You may resume taking your Aspirin and Celebrex on ___. · Do not take any other anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen etc. until follow up. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: · Mild tenderness along the incisions. · Soreness in your arms from the intravenous lines. · 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. Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Severe Constipation · Blood in your stool or urine · Nausea and/or vomiting · Extreme sleepiness · 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 You were discharged on an antibiotic for a urinary tract medication. Please take as prescribed. Followup Instructions: ___
[ "G20", "T85120A", "I4891", "R319", "I2510", "Y658", "E785", "K219", "Z951", "Y92234", "Z955", "Z7982" ]
Allergies: Sulfa(Sulfonamide Antibiotics) / Lyrica Chief Complaint: parkinsons disease Major Surgical or Invasive Procedure: right DBS lead placement and removal Dr [MASKED] on [MASKED] History of Present Illness: This iis aa [MASKED] year old male who presents today electivey for right sided DBS stage 1&2 Past Medical History: [MASKED] disease atrial fibrillation s/p ablation three-vessel coronary artery bypass graft in [MASKED] dyslipidemia ischemic heart disease stent intention tremor myocardial infarction [MASKED] reflus Social History: [MASKED] Family History: Family history is significant for [MASKED] disease in the patient's mother. Physical Exam: [MASKED]: bilateral tremors in all four extremities noted. alert and oriented to person/place/time strength is full no pronator drift EOM intact face symmetric pupils [MASKED] bilaterally Brief Hospital Course: This is a [MASKED] year old male with [MASKED] Disease and s/p left sided DBS who presents electively for a right sided DBS stage 1 and 2 today. The patients pre existing left sided DBS was turned off prior to his pre operative MRI. The patient was taken to the OR and tolerated the procedure well. The post operative imaging was consistent with improper lead positioning. The patient was taken back to the OR for lead removal. The patient left the OR and did not have any right sided DBS hardware in place. The patient was recovered in the PACU. The patient preexisting left sided DBS was turned back on by the [MASKED] representative in the PACU. When the patient was fully recovered from anesthesia they were transferred to the neurosurgery floor. The patients diet was advanced and was able to ambulate. On POD1 he remained stable and was discharged home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amantadine 100 mg PO [MASKED] TIMES A DAY: PRN parkinsons 2. Carbidopa-Levodopa ([MASKED]) 1 TAB PO QID 3. Lodosyn (carbidopa) 25 mg oral [MASKED] times a day parkinsons disease 4. Carvedilol 3.125 mg PO Q AM 5. Celebrex [MASKED] mg oral Q24H 6. Duloxetine 60 mg PO DAILY 7. Enalapril Maleate 5 mg PO QD:PRN for sbp >140 8. Lorazepam 1 mg PO QD PRN anxiety 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN pain 10. Simvastatin 10 mg PO QPM 11. Aspirin 81 mg PO DAILY 12. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 300mg-300mg oral qd 13. Fish Oil (Omega 3) Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Do not exceed 4G of acetaminophen in a 24 hour period. 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. Codeine Sulfate [MASKED] mg PO Q4H:PRN headache RX *codeine sulfate 15 mg [MASKED] tablet(s) by mouth prn Disp #*20 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Senna 17.2 mg PO HS 7. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 8. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO QAM 9. Carbidopa-Levodopa CR ([MASKED]) 1 TAB PO QHS 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. Amantadine 100 mg PO [MASKED] TIMES A DAY: PRN parkinsons 12. Aspirin 81 mg PO DAILY ** you may begin retaking on [MASKED]. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 300mg-300mg oral qd 14. Carbidopa-Levodopa ([MASKED]) 1 TAB PO QID 15. Carvedilol 3.125 mg PO Q AM 16. Celecoxib 200 mg ORAL Q24H ** you may begin retaking on [MASKED]. Duloxetine 60 mg PO DAILY 18. Enalapril Maleate 5 mg PO QD:PRN for sbp >140 19. Lodosyn (carbidopa) 25 mg oral [MASKED] times a day parkinsons disease 20. Lorazepam 1 mg PO QD PRN anxiety 21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QD:PRN pain 22. Simvastatin 10 mg PO QPM Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: [MASKED] disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. [MASKED] [MASKED] Brain [MASKED] Surgery · You underwent Stage I of the DBS on the right side, however, the lead had to be removed. You will need to contact Dr. [MASKED] office to schedule another surgery for right sided stages I and II. Activity · You may gradually return to your normal activities, but we recommend you take it easy for the next [MASKED] hours. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. · You may take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much too soon. · Do not go swimming or submerge yourself in water for fourteen (14) days after your procedure. · The dressing covering your head incision(s) may be removed after 48 hours. You may use a damp washcloth to remove any dried blood or iodine from your skin but do not get your head wet in the shower until your staples or sutures are removed. Medications · Resume your normal [MASKED] medications. The neurologist programming your device may adjust your medications once programming begins. · Take any new medications (i.e. pain medications) as directed. · You may resume taking your Aspirin and Celebrex on [MASKED]. · Do not take any other anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen etc. until follow up. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: · Mild tenderness along the incisions. · Soreness in your arms from the intravenous lines. · 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. Call Your Doctor at [MASKED] for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Severe Constipation · Blood in your stool or urine · Nausea and/or vomiting · Extreme sleepiness · 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 You were discharged on an antibiotic for a urinary tract medication. Please take as prescribed. Followup Instructions: [MASKED]
[]
[ "I4891", "I2510", "E785", "K219", "Z951", "Z955" ]
[ "G20: Parkinson's disease", "T85120A: Displacement of implanted electronic neurostimulator of brain electrode (lead), initial encounter", "I4891: Unspecified atrial fibrillation", "R319: Hematuria, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Y658: Other specified misadventures during surgical and medical care", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z951: Presence of aortocoronary bypass graft", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z955: Presence of coronary angioplasty implant and graft", "Z7982: Long term (current) use of aspirin" ]
10,062,981
21,919,539
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Pavulon Attending: ___. Chief Complaint: Nausea, vomiting, unsteady gait Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male followed closely by outpatient neurologist for suspicion of possible ___ diagnosis was scheduled for an outpatient MRI today to evaluate increased tremor, gait changes, decreased memory and mood change. In addition to those symptoms for which the MRI was scheduled, he recently developed new nausea and vomiting over the last ten days. On ___ he awoke during the night to use the bathroom and sustained a fall, for which he was seen in a local ED - as which time his wife mentioned his nausea and vomiting. He had a CXR which revealed a new lung nodule. This morning his wife called ___ Care due to difficulty over the course of the morning with ADLs and continued nausea and vomiting. They recommended that he proceed with his scheduled outpatient MRI, and then take the images to ___ ED for interpretation and further evaluation. He underwent a non-contrast MR-Brain that revealed right frontal and cerebellar edema suspicious for likely underlying lesion. Neurosurgery was consulted for further planning and work-up. Past Medical History: hyperlipidemia hypertension Type II Diabetes possible ___ Diabetic Neuropathy Kidney disease NOS BPH s/p TURP s/p laser eye surgery for retinopathy Social History: ___ Family History: No family history of cancer. Brother deceased at age ___ of unknown cause - had heart disease. Father deceased at age ___ due to MI. Physical Exam: On admission: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round, s/p laser surgery and unreactive to light. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Strength full power ___ throughout. No pronator drift. Baseline BUE tremor noted, increased with use/movement. Sensation: Intact to light touch Toes downgoing bilaterally Coordination: right dysmetria on finger-nose-finger, normal heel to shin Handedness: Left On discharge: PHYSICAL EXAM: VITAL SIGNS: 98.1 138/80 67 18 99% RA General: NAD, awake HEENT: MMM CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No ___ SKIN: No rashes on extremities NEURO: Non-focal, gait not assessed, minimal pill rolling tremor this am prior, strength ___ b/l upper and lower ext, speech fluent, no facial asymmetry, CN III-XII intact PSYCH: Oriented to self and hospital today, pleasant Pertinent Results: ___ CXR: A large mass in the right upper lung measures at least 11.9 x 9.3 cm and likely right hilar adenopathy. ___ MRI head with and without contrast: 1. 1.5 cm right frontal lobe and 1.8 cm right cerebellar hemispheric enhancing lesions with surrounding edema pattern, corresponding to region of FLAIR edema seen on outside hospital MRI. 2. Additional punctate enhancing lesions of the left orbital frontal lobe, left parietal occipital lobe and cerebellar vermis. 3. The constellation of findings are most compatible with metastatic disease with primary neoplasms considered very unlikely. 4. Gradient echo susceptibility focus of the right occipital lobe with associated faint surrounding enhancement, likely representing cavernoma with associated capillary telangiectasia. However, close and attention on followup is recommended. 5. Unchanged minimal 4 mm leftward midline shift with effacement of the right lateral ventricle frontal horn and fourth ventricle. There is no ventriculomegaly. MRI spine ___ IMPRESSION: 1. No evidence of spinal metastasis from patient's recently diagnosed lung cancer. 2. Multilevel multifactorial degenerative disease of the cervical spine, worst at C6-C7 with moderate spinal canal stenosis and moderate to severe bilateral neural foramen narrowing as described above. 3. Mild degenerative disease involving the thoracic spine with disc protrusions at multiple levels as described above. Neural foramen and spinal canal are however patent at all levels. 4. Multilevel multifactorial degenerative disease of the lumbar spine with moderate spinal canal stenosis at L2-L3 and L3-L4 and moderate to severe neural foramen narrowing at multiple levels, especially at L4-L5 and L5-S1 as described above. 5. Stable previously known right cerebellar enhancing metastasis is partially visualized. 6. Right lung mass and mediastinal lymphadenopathy are partially visualized, better evaluated on recent prior CT of the chest. Path from lung biopsy showing adenocarcinoma ___ 05:30PM BLOOD WBC-8.8 RBC-3.71* Hgb-10.2* Hct-30.5* MCV-82 MCH-27.5 MCHC-33.4 RDW-15.5 RDWSD-45.7 Plt ___ ___ 05:10AM BLOOD WBC-13.4*# RBC-4.01* Hgb-11.0* Hct-33.1* MCV-83 MCH-27.4 MCHC-33.2 RDW-15.4 RDWSD-46.0 Plt ___ ___ 07:22AM BLOOD WBC-10.0 RBC-3.73* Hgb-10.2* Hct-30.5* MCV-82 MCH-27.3 MCHC-33.4 RDW-15.1 RDWSD-45.2 Plt ___ ___ 05:30PM BLOOD Neuts-82.8* Lymphs-8.8* Monos-6.3 Eos-1.3 Baso-0.5 Im ___ AbsNeut-7.28* AbsLymp-0.77* AbsMono-0.55 AbsEos-0.11 AbsBaso-0.04 ___ 05:00AM BLOOD ___ PTT-27.6 ___ ___ 05:30PM BLOOD Glucose-190* UreaN-32* Creat-1.5* Na-136 K-4.7 Cl-99 HCO3-29 AnGap-13 ___ 07:22AM BLOOD Glucose-110* UreaN-31* Creat-1.2 Na-136 K-4.6 Cl-101 HCO3-29 AnGap-11 ___ 07:00AM BLOOD ALT-16 AST-18 LD(LDH)-225 AlkPhos-91 TotBili-0.___ w/ ___, T2DM c/b retinopathy and neuropathy, DL, and BPH, who p/w ataxia and nausea, with MRI showing numerous brain masses c/b edema and midline shift, most c/w metastatic process from a thoracic primary. He was initially admitted to ___ and then transferred to oncology service for further workup and management, now found to have primary lung adenocarcinoma, TTF-1 and Napsin positive, negative for p63. # Brain lesions/new metastatic cancer/metastatic lung adenocarcinoma - Most c/w metastatic disease. Lung mass suggestive of thoracic primary. It was biopsied by ___ on ___ revealing lung adenocarcinoma . Total spine MRI revealed no spinal mets. Rad-onc following, simulation done ___ and CK to brain done over two sessions, ___ and ___. Dexamethasone started, please see below for taper instructions. Discharged on 4mg BID to be tapered by 2mg every 3 days. On omeprazole GI ppx which can be stopped when dexamethasone taper is finished. Pt was taken off keppra as he never had any evidence of seizure activity (this was started prophylactically on admission) Neuro oncology was following and will see him in follow up as outpatient. He has follow up with his oncologist ___ to discuss chemotherapy options. he was given vit B12 injection ___ in anticipation of possible receipt of pemetrexed and was started on 1mg of folic acid daily. Note that CT torso showed possible SVC invasion but pt never had hemodynamic compromise, facial erythema/edema, or dyspnea/wheezing. No clinical suggestion of SVC syndrome etc. # Hyperactive, now Hypoactive Delirium - Most likely due to brain mets, prolonged hospitalization, steroids, keppra, and in context of high level of care. Now much improved but waxing and waning. Hard to tell to what component this is secondary to his brain mets. UA and exam not suggestive of active infection. - Avoid Ativan as it is deliriogenic - avoid antidopaminergic agents (Haldol) given ___ - cont 50 seroquel and 50 trazodone QHS - prn IM olanzapine for severe agitation # T2DM, Insulin Dep, c/b retinopathy/neuropathy/nephropathy. Home glargine 24 u was continued and ___ was following for sliding scale adjustment while on dexamethasone. Please follow SSI as attached and see below for instructions on tapering scale while weaning dex. # Acute Urinary Retention # BPH Retained more than 1L urine, likely from immobility and opiates from IP procedure in context of BPH. Had foley placed ___ which was removed ___ and pt was voiding well without issues prior to discharge. Finasteride started ___. # ___: cont carbidopa/levodopa, donepezil # CKD III: creatinine appears stable at 1.4 and downtrended to 1.2 prior to TRANSITIONAL ISSUES: - pt has ___ clinic apt ___ - cont dexamethasone (steroid) for brain swelling, now tapered to 4 mg BID on discharge. Taper will be: 4mg BID x3 days through ___ 4mg in AM and 2mg in BM for 3 days ___ through ___ 2mg BID for three ___ 2mg in AM only for 3 days ___ then stop. When steroids are completed, omeprazole can be stopped. - Diabetes: go down by ___ units of the sliding scale each time the dex is tapered. Aim for 1 unit decrease with incremental steroid taper if his blood sugar is within goal, and 2 units if his sugar is higher and needs more control. Ultimately, he baseline regimen off any steroids should be his home dose of Lantus 24 units at bedtime (unless he has AM or overnight hypoglycemia) Greater than 30 min spent on coordinating and execution of this discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Donepezil 5 mg PO QHS 2. Sertraline 25 mg PO DAILY 3. Doxazosin 2 mg PO HS 4. Atorvastatin 40 mg PO QPM 5. Vitamin D 5000 UNIT PO DAILY 6. Carbidopa-Levodopa (___) 1 TAB PO @ 1700 7. Carbidopa-Levodopa (___) 1.5 TABs PO DAILY AT 0800 AND 1200 Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Carbidopa-Levodopa (___) 1 TAB PO @ 1700 3. Carbidopa-Levodopa (___) 1.5 TABs PO DAILY AT 0800 AND 1200 4. Donepezil 5 mg PO QHS 5. Doxazosin 2 mg PO HS 6. Sertraline 25 mg PO DAILY 7. Vitamin D 5000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Finasteride 5 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. QUEtiapine Fumarate 50 mg PO QHS This is to help you sleep. Talk to your doctor about whether you need to take it at home 12. Senna 17.2 mg PO HS 13. TraZODone 50 mg PO QHS This is to help you sleep. Talk to your doctor about whether you need to take it at home 14. Dexamethasone 4 mg PO Q12H follow taper instructions!! 15. Artificial Tears 2 DROP BOTH EYES TID 16. FoLIC Acid 1 mg PO DAILY 17. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: RUL lung mass Right frontal brain lesion Right cerebellar brain lesion Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had difficulty walking and you had severe nausea. You were found to have metastatic lung cancer to your brain. You had two total fractions of cyber knife to some of your brain tumors. You will need to follow up with your oncologist to start treatment. In the meantime, you were discharged to rehab to help gain some strength back before you go back home. - Your oncologist will follow you closely during your treatments. You need to see her ___ as below. - cont dexamethasone (steroid) for brain swelling, now tapered to 4 mg BID + PPI Taper will be: 4mg BID x3 days through ___ 4mg in AM and 2mg in BM for 3 days ___ through ___ 2mg BID for three days ___ 2mg in AM only for 3 days ___ then stop Please continue the folate and we started vitamin B12 injections which are once every 9 weeks. Followup Instructions: ___
[ "C7931", "G936", "C782", "C771", "C7989", "R443", "N183", "R251", "R260", "R278", "R413", "F39", "R112", "E785", "E11319", "Z794", "E1142", "I129", "Z87891", "Z9181", "G20", "R410", "Z7952", "E0965", "T380X5A", "N401", "R338" ]
Allergies: Pavulon Chief Complaint: Nausea, vomiting, unsteady gait Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male followed closely by outpatient neurologist for suspicion of possible [MASKED] diagnosis was scheduled for an outpatient MRI today to evaluate increased tremor, gait changes, decreased memory and mood change. In addition to those symptoms for which the MRI was scheduled, he recently developed new nausea and vomiting over the last ten days. On [MASKED] he awoke during the night to use the bathroom and sustained a fall, for which he was seen in a local ED - as which time his wife mentioned his nausea and vomiting. He had a CXR which revealed a new lung nodule. This morning his wife called [MASKED] Care due to difficulty over the course of the morning with ADLs and continued nausea and vomiting. They recommended that he proceed with his scheduled outpatient MRI, and then take the images to [MASKED] ED for interpretation and further evaluation. He underwent a non-contrast MR-Brain that revealed right frontal and cerebellar edema suspicious for likely underlying lesion. Neurosurgery was consulted for further planning and work-up. Past Medical History: hyperlipidemia hypertension Type II Diabetes possible [MASKED] Diabetic Neuropathy Kidney disease NOS BPH s/p TURP s/p laser eye surgery for retinopathy Social History: [MASKED] Family History: No family history of cancer. Brother deceased at age [MASKED] of unknown cause - had heart disease. Father deceased at age [MASKED] due to MI. Physical Exam: On admission: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round, s/p laser surgery and unreactive to light. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Strength full power [MASKED] throughout. No pronator drift. Baseline BUE tremor noted, increased with use/movement. Sensation: Intact to light touch Toes downgoing bilaterally Coordination: right dysmetria on finger-nose-finger, normal heel to shin Handedness: Left On discharge: PHYSICAL EXAM: VITAL SIGNS: 98.1 138/80 67 18 99% RA General: NAD, awake HEENT: MMM CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No [MASKED] SKIN: No rashes on extremities NEURO: Non-focal, gait not assessed, minimal pill rolling tremor this am prior, strength [MASKED] b/l upper and lower ext, speech fluent, no facial asymmetry, CN III-XII intact PSYCH: Oriented to self and hospital today, pleasant Pertinent Results: [MASKED] CXR: A large mass in the right upper lung measures at least 11.9 x 9.3 cm and likely right hilar adenopathy. [MASKED] MRI head with and without contrast: 1. 1.5 cm right frontal lobe and 1.8 cm right cerebellar hemispheric enhancing lesions with surrounding edema pattern, corresponding to region of FLAIR edema seen on outside hospital MRI. 2. Additional punctate enhancing lesions of the left orbital frontal lobe, left parietal occipital lobe and cerebellar vermis. 3. The constellation of findings are most compatible with metastatic disease with primary neoplasms considered very unlikely. 4. Gradient echo susceptibility focus of the right occipital lobe with associated faint surrounding enhancement, likely representing cavernoma with associated capillary telangiectasia. However, close and attention on followup is recommended. 5. Unchanged minimal 4 mm leftward midline shift with effacement of the right lateral ventricle frontal horn and fourth ventricle. There is no ventriculomegaly. MRI spine [MASKED] IMPRESSION: 1. No evidence of spinal metastasis from patient's recently diagnosed lung cancer. 2. Multilevel multifactorial degenerative disease of the cervical spine, worst at C6-C7 with moderate spinal canal stenosis and moderate to severe bilateral neural foramen narrowing as described above. 3. Mild degenerative disease involving the thoracic spine with disc protrusions at multiple levels as described above. Neural foramen and spinal canal are however patent at all levels. 4. Multilevel multifactorial degenerative disease of the lumbar spine with moderate spinal canal stenosis at L2-L3 and L3-L4 and moderate to severe neural foramen narrowing at multiple levels, especially at L4-L5 and L5-S1 as described above. 5. Stable previously known right cerebellar enhancing metastasis is partially visualized. 6. Right lung mass and mediastinal lymphadenopathy are partially visualized, better evaluated on recent prior CT of the chest. Path from lung biopsy showing adenocarcinoma [MASKED] 05:30PM BLOOD WBC-8.8 RBC-3.71* Hgb-10.2* Hct-30.5* MCV-82 MCH-27.5 MCHC-33.4 RDW-15.5 RDWSD-45.7 Plt [MASKED] [MASKED] 05:10AM BLOOD WBC-13.4*# RBC-4.01* Hgb-11.0* Hct-33.1* MCV-83 MCH-27.4 MCHC-33.2 RDW-15.4 RDWSD-46.0 Plt [MASKED] [MASKED] 07:22AM BLOOD WBC-10.0 RBC-3.73* Hgb-10.2* Hct-30.5* MCV-82 MCH-27.3 MCHC-33.4 RDW-15.1 RDWSD-45.2 Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-82.8* Lymphs-8.8* Monos-6.3 Eos-1.3 Baso-0.5 Im [MASKED] AbsNeut-7.28* AbsLymp-0.77* AbsMono-0.55 AbsEos-0.11 AbsBaso-0.04 [MASKED] 05:00AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 05:30PM BLOOD Glucose-190* UreaN-32* Creat-1.5* Na-136 K-4.7 Cl-99 HCO3-29 AnGap-13 [MASKED] 07:22AM BLOOD Glucose-110* UreaN-31* Creat-1.2 Na-136 K-4.6 Cl-101 HCO3-29 AnGap-11 [MASKED] 07:00AM BLOOD ALT-16 AST-18 LD(LDH)-225 AlkPhos-91 TotBili-0.[MASKED] w/ [MASKED], T2DM c/b retinopathy and neuropathy, DL, and BPH, who p/w ataxia and nausea, with MRI showing numerous brain masses c/b edema and midline shift, most c/w metastatic process from a thoracic primary. He was initially admitted to [MASKED] and then transferred to oncology service for further workup and management, now found to have primary lung adenocarcinoma, TTF-1 and Napsin positive, negative for p63. # Brain lesions/new metastatic cancer/metastatic lung adenocarcinoma - Most c/w metastatic disease. Lung mass suggestive of thoracic primary. It was biopsied by [MASKED] on [MASKED] revealing lung adenocarcinoma . Total spine MRI revealed no spinal mets. Rad-onc following, simulation done [MASKED] and CK to brain done over two sessions, [MASKED] and [MASKED]. Dexamethasone started, please see below for taper instructions. Discharged on 4mg BID to be tapered by 2mg every 3 days. On omeprazole GI ppx which can be stopped when dexamethasone taper is finished. Pt was taken off keppra as he never had any evidence of seizure activity (this was started prophylactically on admission) Neuro oncology was following and will see him in follow up as outpatient. He has follow up with his oncologist [MASKED] to discuss chemotherapy options. he was given vit B12 injection [MASKED] in anticipation of possible receipt of pemetrexed and was started on 1mg of folic acid daily. Note that CT torso showed possible SVC invasion but pt never had hemodynamic compromise, facial erythema/edema, or dyspnea/wheezing. No clinical suggestion of SVC syndrome etc. # Hyperactive, now Hypoactive Delirium - Most likely due to brain mets, prolonged hospitalization, steroids, keppra, and in context of high level of care. Now much improved but waxing and waning. Hard to tell to what component this is secondary to his brain mets. UA and exam not suggestive of active infection. - Avoid Ativan as it is deliriogenic - avoid antidopaminergic agents (Haldol) given [MASKED] - cont 50 seroquel and 50 trazodone QHS - prn IM olanzapine for severe agitation # T2DM, Insulin Dep, c/b retinopathy/neuropathy/nephropathy. Home glargine 24 u was continued and [MASKED] was following for sliding scale adjustment while on dexamethasone. Please follow SSI as attached and see below for instructions on tapering scale while weaning dex. # Acute Urinary Retention # BPH Retained more than 1L urine, likely from immobility and opiates from IP procedure in context of BPH. Had foley placed [MASKED] which was removed [MASKED] and pt was voiding well without issues prior to discharge. Finasteride started [MASKED]. # [MASKED]: cont carbidopa/levodopa, donepezil # CKD III: creatinine appears stable at 1.4 and downtrended to 1.2 prior to TRANSITIONAL ISSUES: - pt has [MASKED] clinic apt [MASKED] - cont dexamethasone (steroid) for brain swelling, now tapered to 4 mg BID on discharge. Taper will be: 4mg BID x3 days through [MASKED] 4mg in AM and 2mg in BM for 3 days [MASKED] through [MASKED] 2mg BID for three [MASKED] 2mg in AM only for 3 days [MASKED] then stop. When steroids are completed, omeprazole can be stopped. - Diabetes: go down by [MASKED] units of the sliding scale each time the dex is tapered. Aim for 1 unit decrease with incremental steroid taper if his blood sugar is within goal, and 2 units if his sugar is higher and needs more control. Ultimately, he baseline regimen off any steroids should be his home dose of Lantus 24 units at bedtime (unless he has AM or overnight hypoglycemia) Greater than 30 min spent on coordinating and execution of this discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Donepezil 5 mg PO QHS 2. Sertraline 25 mg PO DAILY 3. Doxazosin 2 mg PO HS 4. Atorvastatin 40 mg PO QPM 5. Vitamin D 5000 UNIT PO DAILY 6. Carbidopa-Levodopa ([MASKED]) 1 TAB PO @ 1700 7. Carbidopa-Levodopa ([MASKED]) 1.5 TABs PO DAILY AT 0800 AND 1200 Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Carbidopa-Levodopa ([MASKED]) 1 TAB PO @ 1700 3. Carbidopa-Levodopa ([MASKED]) 1.5 TABs PO DAILY AT 0800 AND 1200 4. Donepezil 5 mg PO QHS 5. Doxazosin 2 mg PO HS 6. Sertraline 25 mg PO DAILY 7. Vitamin D 5000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Finasteride 5 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. QUEtiapine Fumarate 50 mg PO QHS This is to help you sleep. Talk to your doctor about whether you need to take it at home 12. Senna 17.2 mg PO HS 13. TraZODone 50 mg PO QHS This is to help you sleep. Talk to your doctor about whether you need to take it at home 14. Dexamethasone 4 mg PO Q12H follow taper instructions!! 15. Artificial Tears 2 DROP BOTH EYES TID 16. FoLIC Acid 1 mg PO DAILY 17. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: RUL lung mass Right frontal brain lesion Right cerebellar brain lesion Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you had difficulty walking and you had severe nausea. You were found to have metastatic lung cancer to your brain. You had two total fractions of cyber knife to some of your brain tumors. You will need to follow up with your oncologist to start treatment. In the meantime, you were discharged to rehab to help gain some strength back before you go back home. - Your oncologist will follow you closely during your treatments. You need to see her [MASKED] as below. - cont dexamethasone (steroid) for brain swelling, now tapered to 4 mg BID + PPI Taper will be: 4mg BID x3 days through [MASKED] 4mg in AM and 2mg in BM for 3 days [MASKED] through [MASKED] 2mg BID for three days [MASKED] 2mg in AM only for 3 days [MASKED] then stop Please continue the folate and we started vitamin B12 injections which are once every 9 weeks. Followup Instructions: [MASKED]
[]
[ "E785", "Z794", "I129", "Z87891" ]
[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "C782: Secondary malignant neoplasm of pleura", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "C7989: Secondary malignant neoplasm of other specified sites", "R443: Hallucinations, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "R251: Tremor, unspecified", "R260: Ataxic gait", "R278: Other lack of coordination", "R413: Other amnesia", "F39: Unspecified mood [affective] disorder", "R112: Nausea with vomiting, unspecified", "E785: Hyperlipidemia, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z794: Long term (current) use of insulin", "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", "Z87891: Personal history of nicotine dependence", "Z9181: History of falling", "G20: Parkinson's disease", "R410: Disorientation, unspecified", "Z7952: Long term (current) use of systemic steroids", "E0965: Drug or chemical induced diabetes mellitus with hyperglycemia", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine" ]
10,062,981
24,520,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right hip pain; altered mental status. Major Surgical or Invasive Procedure: none. History of Present Illness: Pt is a ___ PMHx ___, HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain. He was admitted to ___ earlier this month after a 2 week history of nausea and vomiting as well as ataxia. MRI showed numerous brain masses c/b edema and midline shift, most c/w metastatic process for a thoracic primary. Oncologic work-up resulted in diagnosis of primary lung adenocarcinoma, TTF-1 and Napsin positive, negative for p63. He was discharged on a decadron taper (completed on ___, and also recently completed treatment for pan-sensitive E.coli UTI with amoxicillin (completed on ___. He completed cyberknife to the brain and had been improving at rehab. He was most recently see by Dr. ___ on ___ per the clinic note, they discussed that chemotherapy would be palliative, not curative. Initiation of chemotherapy was deferred pending his recovery at rehab and improvement of his performance status. The tentative plan is for eventual chemo with ___ q3 weeks. Since going to rehab he and his report that he was diagnosed with a UTI and was given a course of abx though does not remember the name of the antibiotics. He was apparently making tremendous progress at rehab however one week ago, he and his wife noted that he was very fatigued and tired. This progressively worsened and on ___ while in the bathroom he feel on to his RLE. He remembers the entire event and attributes his fall to being fatigued and weak. Denies chest pain/SOB, nausea/vomiting/diarrhea. Over the weekend he complained of right hip pain. Given symptoms he was brought the ED for evaluation. In the ED, initial VS were 97.9, 86, 129/54, 12, 98% on RA. Physical exam felt to be c/w pelvic fracture. Labs were notable for Cr 1.4 (baseline 1.2-1.4), LFTs wnl, WBC 7, Hgb/Hct 8.8/26.7 (baseline ___, Plt 138. Lact 1.0. Plain film of the hip/pelvis showed no fracture. UA notable for large leuk, + nitr, 100 prot, > 182 WBC, and many bacteria. CT abdomen/pelvis showed large soft tissue lesion c/w bony metastasis involving the right acetabulum with cortical breakthrough with high-risk for fracture. Head CT showed just mildly increased edema of the R cerebellum. Ortho was consulted who recommended non-operative management. Patient recent diagnosed with UTI that grew pansensitive Ecoli. The patient was given 1gm IV ceftriaxone in the ED prior to transfer. On arrival to the floor, patient reports improved pain though still has mild pain. Overall feels weakened but not confused. REVIEW OF SYSTEMS: 10 point review of systems was reviewed and otherwise negative. PAST ONCOLOGIC HISTORY Past Medical History: hyperlipidemia hypertension Type II Diabetes possible ___ Diabetic Neuropathy Kidney disease NOS BPH s/p TURP s/p laser eye surgery for retinopathy Social History: ___ Family History: No family history of cancer. Brother deceased at age ___ of unknown cause - had heart disease. Father deceased at age ___ due to MI. Physical Exam: ADMISSION: VS: 164.2lbs 98.1 106/60 92 18 97% RA Gen: chronically ill appearing NAD HEENT: dry MM EOMI PERRL CV: nl s1s2 RRR Pulm: CTAB Abd: abd, soft NT ND +BS Ext: no edema, Tender on movement of right hip Skin: no clear lesions Neuro: AAOx3 Psych: calm DISCHARGE: VS: 98.2, 127/66, 81, 17, 99% RA Is/Os: ___ last shift; ___ last 24 hours FSBG: 67 this am; 95-174 last 24 hours Gen: NAD, laying comfortably in bed HEENT: NC/AT, MM dry, but no petechiae or oropharyngeal lesions CV: RRR, no m/r/g Pulm: CTAB no fair air movement throughout; no wheezes, rhonchi, or crackles Abd: abd, soft NT, +BS Ext: well perfused, warm, no edema. Skin: dry, no rash Neuro: AAOx3, baseline resting tremor most noticeable in R hand Pertinent Results: ADMISSION LABS: --------------- ___ 11:53AM BLOOD WBC-7.0 RBC-3.25* Hgb-8.8* Hct-26.7* MCV-82 MCH-27.1 MCHC-33.0 RDW-15.8* RDWSD-46.7* Plt ___ ___ 11:53AM BLOOD Neuts-84.7* Lymphs-6.3* Monos-6.3 Eos-2.0 Baso-0.3 Im ___ AbsNeut-5.96 AbsLymp-0.44* AbsMono-0.44 AbsEos-0.14 AbsBaso-0.02 ___ 11:53AM BLOOD Glucose-69* UreaN-26* Creat-1.4* Na-140 K-4.5 Cl-102 HCO3-29 AnGap-14 ___ 11:53AM BLOOD ALT-16 AST-21 AlkPhos-93 TotBili-0.6 DISCHARGE LABS: --------------- ___ 06:40AM BLOOD WBC-7.2 RBC-3.08* Hgb-8.3* Hct-25.5* MCV-83 MCH-26.9 MCHC-32.5 RDW-17.5* RDWSD-50.0* Plt ___ ___ 06:50AM BLOOD Glucose-67* UreaN-29* Creat-1.6* Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 ___ 06:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 PERTINENT STUDIES: ----------------- ___ 01:05PM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 ___ 06:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: ------ ___ Urine Cx ESCHERICHIA COLI AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: -------- ___ MRI Brain 1. Mixed response with interval decrease in the metastatic lesions to the right frontal, left frontal, left parietal lobes and left cerebellar hemisphere, unchanged metastatic lesions in the right cerebellar hemisphere and right parietal lobe, and a new metastatic lesion in the left postcentral gyrus. 2. No evidence of leptomeningeal disease. 3. Unchanged right parietal lobe lesion with susceptibility and faint surrounding enhancement, which may represent a cavernoma. ___ CT ABD/PELVIS 1. Large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture. 2. No hematoma or other acute findings. ___ CT HEAD W/O CONTRAST C/w MRI dated ___. Vasogenic edema in the right frontal lobe and right cerebellum secondary to known metastatic lesions. Mildly increased edema in the right cerebellum. No hemorrhage. ___ CXR FINDINGS: AP upright and lateral views of the chest provided.Again seen is a large mass projecting over the right upper lobe measuring 12.5 x 10 cm, grossly unchanged in size from prior study. Remainder of the right lung is clear. Left lung is clear. No large effusion or pneumothorax. Heart size remains within normal limits. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Large mass in the right upper lung. Otherwise unremarkable. Brief Hospital Course: ___ PMHx ___, HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain who presented from rehab status post fall with confusion found to have large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture of the hip, and persistent E. Coli UTI. # R hip pain/R Acetabular Metastatic Lesions: Secondary to bony metastasis from known primary stage IV lung adenocarcinoma. He was evaluated by orthopedic surgery in the ER, who felt that the patient was at high risk for fracture, but recommended he remain weight bearing as tolerated. Surgery was not offered. He received palliative XRT for a total of 5 fractions with the last session on ___. Pain was managed with standing tylenol and PRN oxycodone. He continued to work with physical therapy during his stay with a goal of home discharge. # UTI: Patient developed his first UTI while at rehab, which was reportedly a pan-sensitive E. coli treated with augmentin for an unknown duration. He was again noted to have a UTI upon presentation to the ED. It is unclear if he ever cleared his previous infection. Cultures again notable for pan-sensitive E. Coli. Rectal Exam not concerning for prostatitis. He received five days of IV ceftriaxone and ultimately cleared his urine, at which time he was transitioned to PO bactrim for a total of 14 days of antibiotics for complicated UTI. Prior to discharge, due to rising Cr, he was transitioned to PO ciprofloxacin with course to be completed on ___. #Acute Toxic Metabolic Encephalopathy: The patient presented with AMS without clear etiology. Differential included mental status change ___ urinary infection, pain from hip lesion, and worsening brain disease with edema noted on CT and MRI showing mixed response to radiation with new lesion in postcentral gyrus, especially in setting of recent steroid taper. Patient also with known ___ Disease, which was likely contributing. He was started on dexamethasone 2mg BID, which was tapered to 2mg daily. Concurrently, his UTI was treated and his mental status improved. He was discharged on dexamethasone 2mg PO daily with final decision regarding duration per neuro-onc follow-up. # Stage IV NSCLC: Per outpatient records, the patient was to start chemotherapy after his performance status improved with rehab. This re-admission further delayed chemotherapy and goals of care ongoing at time of discharge. On discharge, he was to follow up with Atrius Oncology for further management of his cancer. CHRONIC ISSUES: ========================== # ___ disease: The patient was continued on his home dose of sinemet. # T2DM: The patient was continued on lantus and HISS as well as a diabetic diet. Adjustments were made to regimen in setting of poor PO intake and then when steroids were initiated. Please refer to discharge medications for insulin regimen at time of discharge. # HLD: He was continued on his home atorvastatin. # CKD: The patient's Cr was monitored closely during this admission and prior to discharge, he did have rise in Cr ___ bactrim. He was switched to PO cipro for this reason. He was to have repeat Cr drawn at next follow-up. TRANSITIONAL ISSUES: ===================== - Will need to take Cipro 500 BID until ___ - Please repeat GFR at next follow up and evaluate for any new confusion (potential side effect of Cipro) - Discharged on 2mg dexamethasone/day until Neuro-Onc follow up - Atrius Oncology Follow up - Brain Metastases: The question new metastasis in the left postcentral gyrus needs to be followed up. # CODE: DNR/DNI # EMERGENCY CONTACT/HCP: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 3. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 4. Donepezil 5 mg PO QHS 5. Sertraline 25 mg PO DAILY 6. Vitamin D 5000 UNIT PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Omeprazole 40 mg PO DAILY 9. QUEtiapine Fumarate 50 mg PO QHS 10. Senna 17.2 mg PO QHS 11. TraZODone 50 mg PO QHS 12. FoLIC Acid 1 mg PO DAILY 13. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Artificial Tears 2 DROP BOTH EYES TID 15. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Artificial Tears 2 DROP BOTH EYES TID 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. Sertraline 25 mg PO DAILY 11. Vitamin D 5000 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q8H pain 13. Dexamethasone 2 mg PO DAILY RX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 Disp #*20 Tablet Refills:*0 15. Polyethylene Glycol 17 g PO TID RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth twice a day Refills:*0 16. Rolling Walker Diagnosis - R53.81 Prognosis - good Length of time - 13mo 17. Ciprofloxacin HCl 500 mg PO Q12H last day ___ RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 18. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary: bony metastasis of right acetabulum; urinary tract infection; encephalopathy. secondary: Stage IV NSCLC; ___ Disease; Diiabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted to the hospital after falling while you were at rehab. Imaging revealed that tumor had spread to your hip. You were evaluated by our orthopedic surgeons who did not feel that surgery was indicated. You were treated with radiation therapy to help improve your pain. You were also restarted on steroids to prevent brain swelling from your known tumors. Additionally, you were found to have a urinary tract infection and treated with antibiotics. Please follow up with all scheduled appointments and continue taking all medications as prescribed. If you develop any of the danger signs below, please contact your health care providers or go to the emergency room immediately. PLEASE SEE THAT YOUR NEW INSULIN DOSE IS LOWER THAN BEFORE We wish you the best. Sincerely, Your ___ team Followup Instructions: ___
[ "C7951", "G92", "C7931", "N390", "E1140", "C3490", "D696", "E11649", "B9620", "F19939", "E785", "Z66", "G20", "D649", "I129", "N189", "Z87891", "Z794" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right hip pain; altered mental status. Major Surgical or Invasive Procedure: none. History of Present Illness: Pt is a [MASKED] PMHx [MASKED], HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain. He was admitted to [MASKED] earlier this month after a 2 week history of nausea and vomiting as well as ataxia. MRI showed numerous brain masses c/b edema and midline shift, most c/w metastatic process for a thoracic primary. Oncologic work-up resulted in diagnosis of primary lung adenocarcinoma, TTF-1 and Napsin positive, negative for p63. He was discharged on a decadron taper (completed on [MASKED], and also recently completed treatment for pan-sensitive E.coli UTI with amoxicillin (completed on [MASKED]. He completed cyberknife to the brain and had been improving at rehab. He was most recently see by Dr. [MASKED] on [MASKED] per the clinic note, they discussed that chemotherapy would be palliative, not curative. Initiation of chemotherapy was deferred pending his recovery at rehab and improvement of his performance status. The tentative plan is for eventual chemo with [MASKED] q3 weeks. Since going to rehab he and his report that he was diagnosed with a UTI and was given a course of abx though does not remember the name of the antibiotics. He was apparently making tremendous progress at rehab however one week ago, he and his wife noted that he was very fatigued and tired. This progressively worsened and on [MASKED] while in the bathroom he feel on to his RLE. He remembers the entire event and attributes his fall to being fatigued and weak. Denies chest pain/SOB, nausea/vomiting/diarrhea. Over the weekend he complained of right hip pain. Given symptoms he was brought the ED for evaluation. In the ED, initial VS were 97.9, 86, 129/54, 12, 98% on RA. Physical exam felt to be c/w pelvic fracture. Labs were notable for Cr 1.4 (baseline 1.2-1.4), LFTs wnl, WBC 7, Hgb/Hct 8.8/26.7 (baseline [MASKED], Plt 138. Lact 1.0. Plain film of the hip/pelvis showed no fracture. UA notable for large leuk, + nitr, 100 prot, > 182 WBC, and many bacteria. CT abdomen/pelvis showed large soft tissue lesion c/w bony metastasis involving the right acetabulum with cortical breakthrough with high-risk for fracture. Head CT showed just mildly increased edema of the R cerebellum. Ortho was consulted who recommended non-operative management. Patient recent diagnosed with UTI that grew pansensitive Ecoli. The patient was given 1gm IV ceftriaxone in the ED prior to transfer. On arrival to the floor, patient reports improved pain though still has mild pain. Overall feels weakened but not confused. REVIEW OF SYSTEMS: 10 point review of systems was reviewed and otherwise negative. PAST ONCOLOGIC HISTORY Past Medical History: hyperlipidemia hypertension Type II Diabetes possible [MASKED] Diabetic Neuropathy Kidney disease NOS BPH s/p TURP s/p laser eye surgery for retinopathy Social History: [MASKED] Family History: No family history of cancer. Brother deceased at age [MASKED] of unknown cause - had heart disease. Father deceased at age [MASKED] due to MI. Physical Exam: ADMISSION: VS: 164.2lbs 98.1 106/60 92 18 97% RA Gen: chronically ill appearing NAD HEENT: dry MM EOMI PERRL CV: nl s1s2 RRR Pulm: CTAB Abd: abd, soft NT ND +BS Ext: no edema, Tender on movement of right hip Skin: no clear lesions Neuro: AAOx3 Psych: calm DISCHARGE: VS: 98.2, 127/66, 81, 17, 99% RA Is/Os: [MASKED] last shift; [MASKED] last 24 hours FSBG: 67 this am; 95-174 last 24 hours Gen: NAD, laying comfortably in bed HEENT: NC/AT, MM dry, but no petechiae or oropharyngeal lesions CV: RRR, no m/r/g Pulm: CTAB no fair air movement throughout; no wheezes, rhonchi, or crackles Abd: abd, soft NT, +BS Ext: well perfused, warm, no edema. Skin: dry, no rash Neuro: AAOx3, baseline resting tremor most noticeable in R hand Pertinent Results: ADMISSION LABS: --------------- [MASKED] 11:53AM BLOOD WBC-7.0 RBC-3.25* Hgb-8.8* Hct-26.7* MCV-82 MCH-27.1 MCHC-33.0 RDW-15.8* RDWSD-46.7* Plt [MASKED] [MASKED] 11:53AM BLOOD Neuts-84.7* Lymphs-6.3* Monos-6.3 Eos-2.0 Baso-0.3 Im [MASKED] AbsNeut-5.96 AbsLymp-0.44* AbsMono-0.44 AbsEos-0.14 AbsBaso-0.02 [MASKED] 11:53AM BLOOD Glucose-69* UreaN-26* Creat-1.4* Na-140 K-4.5 Cl-102 HCO3-29 AnGap-14 [MASKED] 11:53AM BLOOD ALT-16 AST-21 AlkPhos-93 TotBili-0.6 DISCHARGE LABS: --------------- [MASKED] 06:40AM BLOOD WBC-7.2 RBC-3.08* Hgb-8.3* Hct-25.5* MCV-83 MCH-26.9 MCHC-32.5 RDW-17.5* RDWSD-50.0* Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-67* UreaN-29* Creat-1.6* Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 [MASKED] 06:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 PERTINENT STUDIES: ----------------- [MASKED] 01:05PM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 [MASKED] 06:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: ------ [MASKED] Urine Cx ESCHERICHIA COLI AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: -------- [MASKED] MRI Brain 1. Mixed response with interval decrease in the metastatic lesions to the right frontal, left frontal, left parietal lobes and left cerebellar hemisphere, unchanged metastatic lesions in the right cerebellar hemisphere and right parietal lobe, and a new metastatic lesion in the left postcentral gyrus. 2. No evidence of leptomeningeal disease. 3. Unchanged right parietal lobe lesion with susceptibility and faint surrounding enhancement, which may represent a cavernoma. [MASKED] CT ABD/PELVIS 1. Large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture. 2. No hematoma or other acute findings. [MASKED] CT HEAD W/O CONTRAST C/w MRI dated [MASKED]. Vasogenic edema in the right frontal lobe and right cerebellum secondary to known metastatic lesions. Mildly increased edema in the right cerebellum. No hemorrhage. [MASKED] CXR FINDINGS: AP upright and lateral views of the chest provided.Again seen is a large mass projecting over the right upper lobe measuring 12.5 x 10 cm, grossly unchanged in size from prior study. Remainder of the right lung is clear. Left lung is clear. No large effusion or pneumothorax. Heart size remains within normal limits. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Large mass in the right upper lung. Otherwise unremarkable. Brief Hospital Course: [MASKED] PMHx [MASKED], HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain who presented from rehab status post fall with confusion found to have large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture of the hip, and persistent E. Coli UTI. # R hip pain/R Acetabular Metastatic Lesions: Secondary to bony metastasis from known primary stage IV lung adenocarcinoma. He was evaluated by orthopedic surgery in the ER, who felt that the patient was at high risk for fracture, but recommended he remain weight bearing as tolerated. Surgery was not offered. He received palliative XRT for a total of 5 fractions with the last session on [MASKED]. Pain was managed with standing tylenol and PRN oxycodone. He continued to work with physical therapy during his stay with a goal of home discharge. # UTI: Patient developed his first UTI while at rehab, which was reportedly a pan-sensitive E. coli treated with augmentin for an unknown duration. He was again noted to have a UTI upon presentation to the ED. It is unclear if he ever cleared his previous infection. Cultures again notable for pan-sensitive E. Coli. Rectal Exam not concerning for prostatitis. He received five days of IV ceftriaxone and ultimately cleared his urine, at which time he was transitioned to PO bactrim for a total of 14 days of antibiotics for complicated UTI. Prior to discharge, due to rising Cr, he was transitioned to PO ciprofloxacin with course to be completed on [MASKED]. #Acute Toxic Metabolic Encephalopathy: The patient presented with AMS without clear etiology. Differential included mental status change [MASKED] urinary infection, pain from hip lesion, and worsening brain disease with edema noted on CT and MRI showing mixed response to radiation with new lesion in postcentral gyrus, especially in setting of recent steroid taper. Patient also with known [MASKED] Disease, which was likely contributing. He was started on dexamethasone 2mg BID, which was tapered to 2mg daily. Concurrently, his UTI was treated and his mental status improved. He was discharged on dexamethasone 2mg PO daily with final decision regarding duration per neuro-onc follow-up. # Stage IV NSCLC: Per outpatient records, the patient was to start chemotherapy after his performance status improved with rehab. This re-admission further delayed chemotherapy and goals of care ongoing at time of discharge. On discharge, he was to follow up with Atrius Oncology for further management of his cancer. CHRONIC ISSUES: ========================== # [MASKED] disease: The patient was continued on his home dose of sinemet. # T2DM: The patient was continued on lantus and HISS as well as a diabetic diet. Adjustments were made to regimen in setting of poor PO intake and then when steroids were initiated. Please refer to discharge medications for insulin regimen at time of discharge. # HLD: He was continued on his home atorvastatin. # CKD: The patient's Cr was monitored closely during this admission and prior to discharge, he did have rise in Cr [MASKED] bactrim. He was switched to PO cipro for this reason. He was to have repeat Cr drawn at next follow-up. TRANSITIONAL ISSUES: ===================== - Will need to take Cipro 500 BID until [MASKED] - Please repeat GFR at next follow up and evaluate for any new confusion (potential side effect of Cipro) - Discharged on 2mg dexamethasone/day until Neuro-Onc follow up - Atrius Oncology Follow up - Brain Metastases: The question new metastasis in the left postcentral gyrus needs to be followed up. # CODE: DNR/DNI # EMERGENCY CONTACT/HCP: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO Q8AM AND Q12PM 3. Carbidopa-Levodopa ([MASKED]) 1 TAB PO Q5PM 4. Donepezil 5 mg PO QHS 5. Sertraline 25 mg PO DAILY 6. Vitamin D 5000 UNIT PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Omeprazole 40 mg PO DAILY 9. QUEtiapine Fumarate 50 mg PO QHS 10. Senna 17.2 mg PO QHS 11. TraZODone 50 mg PO QHS 12. FoLIC Acid 1 mg PO DAILY 13. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Artificial Tears 2 DROP BOTH EYES TID 15. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Artificial Tears 2 DROP BOTH EYES TID 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa ([MASKED]) 1 TAB PO Q5PM 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. Sertraline 25 mg PO DAILY 11. Vitamin D 5000 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q8H pain 13. Dexamethasone 2 mg PO DAILY RX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 Disp #*20 Tablet Refills:*0 15. Polyethylene Glycol 17 g PO TID RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth twice a day Refills:*0 16. Rolling Walker Diagnosis - R53.81 Prognosis - good Length of time - 13mo 17. Ciprofloxacin HCl 500 mg PO Q12H last day [MASKED] RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 18. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: primary: bony metastasis of right acetabulum; urinary tract infection; encephalopathy. secondary: Stage IV NSCLC; [MASKED] Disease; Diiabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a privilege to care for you at the [MASKED] [MASKED]. You were admitted to the hospital after falling while you were at rehab. Imaging revealed that tumor had spread to your hip. You were evaluated by our orthopedic surgeons who did not feel that surgery was indicated. You were treated with radiation therapy to help improve your pain. You were also restarted on steroids to prevent brain swelling from your known tumors. Additionally, you were found to have a urinary tract infection and treated with antibiotics. Please follow up with all scheduled appointments and continue taking all medications as prescribed. If you develop any of the danger signs below, please contact your health care providers or go to the emergency room immediately. PLEASE SEE THAT YOUR NEW INSULIN DOSE IS LOWER THAN BEFORE We wish you the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N390", "D696", "E785", "Z66", "D649", "I129", "N189", "Z87891", "Z794" ]
[ "C7951: Secondary malignant neoplasm of bone", "G92: Toxic encephalopathy", "C7931: Secondary malignant neoplasm of brain", "N390: Urinary tract infection, site not specified", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "D696: Thrombocytopenia, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F19939: Other psychoactive substance use, unspecified with withdrawal, unspecified", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "G20: Parkinson's disease", "D649: Anemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin" ]
10,062,981
26,125,093
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: ___ Cryoablation of Right Acetabular Metastatic Lesion with Cementoplasty History of Present Illness: Mr. ___ is a ___ y/o man with a PMHx ___, HTN, HLD, and recent diagnosis of Stage IV NSCLC with brain mets s/p Cyberknife to the brain with recent admission to OMED ___ after for fall, presenting with another fall. Rgarding his prior admission, he was found to have hip lytic lesion ___ metastasis without clear fracture. Per Trauma ortho, surgery was not recommended. He completed ___ Fr palliative radiation therapy on ___. During the hospitalization, he was also treated with abx for UTI (d/c'ed on cipro) and steroids for cerebral edema related to brain mets. He was discharged on dexamethasone 2mg PO daily. Initially after d/c, the patient was doing OK for few days not requiring oxycodone, ambulating with walker. However, over past ___ days, he has had worsening pain. While he was improving, he did not require any oxycodone, but has been taking PRN oxycodone ___ times/day encouraged by his wife over the past couple days. On ___, when he was walking to turn off the light, he was shocked by the light switch and fell back on his R buttock/hip. He denies any preceding palpitations, LH, dizziness, unsteadiness on her legs, or nausea/flushing. He also denies headstrike or LOC during the fall. His wife was at home during this fall and came to help him up. His pain has been much worse since this fall. He and his wife called his outpatient oncologist, who recommended coming to the ED. In ED, his vitals were 98 80 130/70 16 99% RA and he was noted to have severe pain with manipulation of RLE, He had R pelvis/hip/knee xrays negative for acute frx. On CT, he was found to have increased cortical breakthrough compared to prior imaging 2 weeks prior. He was given 4mg IV morphine x 2 and admitted to oncology for pain control. Overnight, he states that he has had significant pain in his RLE. He denies any f/c/r, chest pain, SOB, abd pain or N/V. He does not have any pain in his left ___. His last BM was on ___. No difficulty making urine or pain with urination. Past Medical History: -Metastatic Non-Small Cell Lung Cancer -Hyperlipidemia -Hypertension -Type II Diabetes -Possible ___ -Diabetic Neuropathy -Kidney disease NOS -BPH s/p TURP -s/p laser eye surgery for retinopathy Social History: ___ Family History: No family history of cancer. Brother deceased at age ___ of unknown cause - had heart disease. Father deceased at age ___ due to MI. Physical Exam: ADMISSION PHYSICAL: -------------------- General: NAD, A&Ox3, sitting comfortably in bed VS: 97.5, 141/65, 75, 18, 98% RA HEENT: NC/AT, wearing glasses; EOMI; PERRL, MM dry Neck: supple, no JVD CV: RRR, no m/r/g PULM: CTAB without crackles, rhonchi, or wheezes ABD: Soft, ND, NTTP, no r/g, BS+ EXT: Warm well perfused, no edema. Able to slowly pull R leg along bed, unable to lift off, full ROM of LLE, exquisitely tender with minimal palpation of RLE from mid-shins proximally SKIN: Clustered, herpetiform lesions, R, paraspinal at level of sacrum, non-crusted, non-weeping NEURO: decreased strength in RLE ___ pain; otherwise grossly intact DISCHARGE EXAM: ---------------- VS: 97.8, 134/70, 65, 16, 99% RA FSBG: 179-244 last 24 hours I/O: 100/500 last 8 hours; 1260/550+ last 24 hours Last BM: recorded as ___ per patient had BM 2 days ago GEN: alert, appropriately interactive; making appropriate eye contact during conversation; pleasant, in NAD HEENT: white haired, bearded, glasses on, MMM; +tongue fasciculations Neck: supple CV: RRR, no m/r/g PULM: CTAB without crackles, rhonchi, or wheezes anteriorly and laterally ABD: Soft, ND, NTTP, no r/g, BS+ EXT: Warm well perfused, no edema; minimal pain with palpation of RLE. Mild discomfort with palpation of lateral aspect of R leg; Low frequency resting pill-rolling tremor in RUE NEURO: A&Ox3, asking why he is in the hospital but no apparent focal deficits Pertinent Results: ADMISSION LABS: ---------------- ___ 08:45PM BLOOD WBC-7.3 RBC-2.94* Hgb-8.1* Hct-24.5* MCV-83 MCH-27.6 MCHC-33.1 RDW-18.0* RDWSD-53.6* Plt ___ ___ 08:45PM BLOOD Neuts-87.7* Lymphs-5.7* Monos-5.6 Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.43* AbsLymp-0.42* AbsMono-0.41 AbsEos-0.01* AbsBaso-0.01 ___ 08:45PM BLOOD Glucose-248* UreaN-25* Creat-1.1 Na-132* K-4.8 Cl-97 HCO3-26 AnGap-14 OTHER IMPORTANT LABS: ___ 12:45AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:45AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:45AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 06:20PM URINE CastGr-3* CastHy-6* ___ 06:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 06:20PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 10:29PM URINE CastGr-1* CastHy-20* ___ 10:29PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:29PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 06:20PM URINE Hours-RANDOM UreaN-514 Creat-120 Na-45 K-47 Cl-42 Phos-74.6 ___ 06:20PM URINE Osmolal-430 ___ 10:30PM URINE Hours-RANDOM Na-30 K-58 Cl-21 ___ 10:30PM URINE Osmolal-473 MICROBIOLOGY: -------------- ___ HSV 1 and 2 Direct Antigen Test: Negative ___ Varicella Zoster Virus Direct Antigen Test: Negative ___ Urine Culture: Negative ___ Urine Culture: Negative IMAGING: --------- ___ Knee ___: No acute fracture or dislocation. ___ Hip ___: No acute fracture or dislocation. Lucent right acetabular lesion not clearly visualized. If strong concern for fracture, CT advised. ___ CT Lower Extremity: A large lytic lesion in the right acetabulum concerning for metastatic disease has slightly increased in size. There is cortical breakthrough as described above but no acute superimposed fracture or dislocation. ___ CT Lower Extremity (Repeat to capture lower leg): There is a right hemi sacral fracture with extension into the S1 neural foramen. Again seen is a 4.2 x 4.4 cm lytic lesion in the superior right acetabulum with apparent extension into the gluteus minimus. Given areas of cortical penetration, an underlying pathologic fracture is not excluded. ___ CT Head without Contrast: Multiple areas of edema at compatible with known brain metastases. No evidence of new lesions although noncontrast CT has limited sensitivity. There is no evidence of hemorrhage. No change since the head CT of ___. ___ CT Head without Contrast: No acute intracranial abnormality on noncontrast head CT. Edema in the right frontal lobe and right cerebellar hemisphere compatible with known metastatic disease, similar to prior exam. Other supratentorial and infratentorial metastatic disease is better assessed on the recent MR. ___ LABS: ---------------- None Brief Hospital Course: Mr. ___ is a ___ y/o man with PMHx ___, HTN, HLD, and recent diagnosis of Stage IV NSCLC with brain mets s/p Cyberknife. He was recently admitted after fall and found to have large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough and completed XRT to this region as well on ___. He was re-admitted 5 days later w/ recurrent mechanical fall at home and exacerbation of R leg pain. ACTIVE PROBLEMS: ------------------ # Right Acetabular Metastases: The patient has had significant RLE pain since prior admission due to known acetabular bony metastases. He completed 5 fractions of XRT on ___, with what appeared to transient improvement in his sx while at home. Prior to re-admission, however, he did, per his wife, begin to have recurring pain, which likely contributed to his fall. During this admission, he had imaging showing largely stable bony mets and was initially managed conservatively with pain medications. Per radiation oncology, he would not be candidate and would not likely benefit from further XRT. He was taken by ___ on ___ for cryoablation of R acetabular mets with cementoplasty with eventual improvement in his symptoms. He tolerated the procedure well and was slowly weaned off opiod medications. Prior to discharge, he was able to ambulate small distances with assistance of ___. # Somnolence likely ___ Hypoactive Toxic-Metabolic Encephalopathy: During this admission, the patient triggered upon being found to be somnolent. He was without any focal neuro deficits, vital signs were within normal limits, and fingerstick blood sugars were normal. Most likely explanation for this acute event was felt to be likely hypoactive delirium in the setting of recent changes in oxycontin dosage and dexamethasone frequency, perhaps with resultant disturbance in sleep-wake cycle. Other considerations included acute intracranial bleed, not visualized on CT Head NC, and seizure. The patient quickly recovered with rapid improvement in mentation. Neuro-oncology was consulted, who did not feel keppra or further work-up for seizure to be indicated. They also recommended continuing the same dosage of dexamethasone pending repeat Brain MRI and neuro-oncology follow up. # Acute Toxic Metabolic Encephalopathy: The patient had acute, waxing-waning mental status changes during this admission. This was also present during his last admission, and was again likely due to combination of pain from his metastatic lesions, sedating medications (mostly opiods), and other metabolic disturbances such as ___ and constipation. With largely treatment of his RLE metastatic lesions with cryo-ablation and cementoplasty and management of his pain, his mental status began to clear. Infection and new, primary CNS process was ruled out given his recent history of UTI and known history of intra-cranial mets. Prior to discharge, Mr. ___ was consistently ___ at his baseline. # Fall due to baseline gait instability/deconditioning: Per patient, he appeared to have suffered a mechanical fall ___ pain and compromised balance I/s/o known ___ Disease and deconditioning (multiple recent hospitalizations). He denied any signs of syncope or seizure or antecendent symptoms suggestive of alternate etiology. He denied any injuries or head strike and imaging ___ in ED w/o fracture as above. CT Head was also unremarkable for any new intracranial abnormalities. His pain was managed as above and he worked closely with ___ throughout this admission prior to ultimate discharge to rehab. # Stage IV NSCLC: The overall plan for Mr. ___ had been to resume chemotherapy after his clinical condition had stabilized, following his most recent admission. This re-admission further delayed chemotherapy and ultimately, his goals of care shifted based on multiple family meetings held during this hospitalization between the patient, his primary team, and palliative care. As he was not felt to be safe at home due to his baseline gait instability and weakness, the patient was discharged to short term rehab with goal of transitioning to home and possibility of hospice thereafter. CHRONIC/STABLE/RESOLVED PROBLEMS: # HSV Dermatitis: The patient developed a small herpetiform rash c/w HSV dermatitis around his sacrum and was treated empirically with 7 days of PO acyclovir with good effect. # ___ due to pre-renal azotemia/Stage II CKD: The patient presented with Cr of 1.1, at baseline, c/w stage II CKD. During this admission, amidst waxing and waning mentation with subsequent poor PO intake, his Cr rose to 1.4. With IVF and encouraged PO, his Cr returned back to baseline. # ___ Disease: The patient was continued on his home dose of Carbidopa/Levadopa during this hospitalization. # Type 2 Diabetes Mellitus: The patient was continued on his home lantus and ISS on admission. This was adjusted due to poor PO intake initially and subsequently re-adjusted for rising FSBG's in the setting of increased steroid dosage. TRANSITIONAL ISSUES: -Per multiple family meetings held during this admission and concerns about medical safety in the home setting, the patient was discharged to short term rehab, with hopes for possible transition to home. -Should patient not be able to come home, consider evaluation for long term placement and/or initiation of hospice services at that time -The patient's steroid dosage for cerebral edema ___ intra-cranial metastases was increased from 2mg PO q24H to 2mg PO q12H. Per Neuro-oncology, the patient was maintained on this dosage on discharge and would need repeat Head MRI and Neuro-Oncology follow-up to decide further steroid regimen. -The patient should follow-up with his primary oncologist regarding setting up any Neuro-Oncology appointments as needed and for further management of his cancer overall -Patient was treated with 7-day course of PO acyclovir for recurrent, local HSV dermatitis (R lumbar back) -Given patient's underlying ___ Disease, the patient should not be given any first-generation anti-psychotic medications or anti-dopaminergic agents -CODE STATUS: DNR/DNI -Contact Information for Primary Oncologist: ___ (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears 2 DROP BOTH EYES TID 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. Sertraline 25 mg PO DAILY 11. Vitamin D 5000 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q8H:PRN pain 13. Dexamethasone 2 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 15. Polyethylene Glycol 17 g PO TID 16. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Artificial Tears 2 DROP BOTH EYES TID 3. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 5. Dexamethasone 2 mg PO Q12H 6. Docusate Sodium 100 mg PO BID 7. Donepezil 5 mg PO QHS 8. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 17.2 mg PO QHS:PRN constipation 12. Sertraline 25 mg PO DAILY 13. Ibuprofen 400 mg PO Q8H 14. Omeprazole 20 mg PO DAILY 15. Atorvastatin 40 mg PO QPM 16. FoLIC Acid 1 mg PO DAILY 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: -Metastatic Non-Small Cell Lung Cancer -Mechanical Fall due to Baseline Gait Instability and Prolonged Deconditioning SECONDARY DIAGNOSIS/ES: -Acute Toxic-Metabolic Encephalopathy -Hemisacral Fracture due to Fall -Metastatic Brain Lesions due to NSCLC and associated Cerebral Edema -Recurrent, Local Herpes Simplex Virus Dermatitis -Acute Kidney Injury due to Pre-Renal Azotemia -Stage 2 Chronic Kidney Disease -___ Disease -Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you felt weak and fell at home. On admission, you were also in a lot of pain from the cancer in your right leg as well as from your fall. You were given medications to help with your pain. You also underwent a procedure to remove some of the cancer in your leg and stabilize the bone. Your pain improved significantly after this procedure and you were even starting to walk with physical therapy. During this hospitalization, we also held a family meeting with you, your wife, and doctors from multiple ___ in the hospital to discuss your overall goals of care. It was felt that you would most benefit from being in a place where you could have supported care 24 hours a day, which you would not be able to receive at home. As such, you were discharged to short term rehab to work on your strength and hopefully be able to transition you back home. Please take note of the changes in your home medications and follow up with your outpatient doctors ___ detailed in the rest of your discharge paperwork). Thank you for allowing us to be a part of your care, Your ___ Team Followup Instructions: ___
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: [MASKED] Cryoablation of Right Acetabular Metastatic Lesion with Cementoplasty History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man with a PMHx [MASKED], HTN, HLD, and recent diagnosis of Stage IV NSCLC with brain mets s/p Cyberknife to the brain with recent admission to OMED [MASKED] after for fall, presenting with another fall. Rgarding his prior admission, he was found to have hip lytic lesion [MASKED] metastasis without clear fracture. Per Trauma ortho, surgery was not recommended. He completed [MASKED] Fr palliative radiation therapy on [MASKED]. During the hospitalization, he was also treated with abx for UTI (d/c'ed on cipro) and steroids for cerebral edema related to brain mets. He was discharged on dexamethasone 2mg PO daily. Initially after d/c, the patient was doing OK for few days not requiring oxycodone, ambulating with walker. However, over past [MASKED] days, he has had worsening pain. While he was improving, he did not require any oxycodone, but has been taking PRN oxycodone [MASKED] times/day encouraged by his wife over the past couple days. On [MASKED], when he was walking to turn off the light, he was shocked by the light switch and fell back on his R buttock/hip. He denies any preceding palpitations, LH, dizziness, unsteadiness on her legs, or nausea/flushing. He also denies headstrike or LOC during the fall. His wife was at home during this fall and came to help him up. His pain has been much worse since this fall. He and his wife called his outpatient oncologist, who recommended coming to the ED. In ED, his vitals were 98 80 130/70 16 99% RA and he was noted to have severe pain with manipulation of RLE, He had R pelvis/hip/knee xrays negative for acute frx. On CT, he was found to have increased cortical breakthrough compared to prior imaging 2 weeks prior. He was given 4mg IV morphine x 2 and admitted to oncology for pain control. Overnight, he states that he has had significant pain in his RLE. He denies any f/c/r, chest pain, SOB, abd pain or N/V. He does not have any pain in his left [MASKED]. His last BM was on [MASKED]. No difficulty making urine or pain with urination. Past Medical History: -Metastatic Non-Small Cell Lung Cancer -Hyperlipidemia -Hypertension -Type II Diabetes -Possible [MASKED] -Diabetic Neuropathy -Kidney disease NOS -BPH s/p TURP -s/p laser eye surgery for retinopathy Social History: [MASKED] Family History: No family history of cancer. Brother deceased at age [MASKED] of unknown cause - had heart disease. Father deceased at age [MASKED] due to MI. Physical Exam: ADMISSION PHYSICAL: -------------------- General: NAD, A&Ox3, sitting comfortably in bed VS: 97.5, 141/65, 75, 18, 98% RA HEENT: NC/AT, wearing glasses; EOMI; PERRL, MM dry Neck: supple, no JVD CV: RRR, no m/r/g PULM: CTAB without crackles, rhonchi, or wheezes ABD: Soft, ND, NTTP, no r/g, BS+ EXT: Warm well perfused, no edema. Able to slowly pull R leg along bed, unable to lift off, full ROM of LLE, exquisitely tender with minimal palpation of RLE from mid-shins proximally SKIN: Clustered, herpetiform lesions, R, paraspinal at level of sacrum, non-crusted, non-weeping NEURO: decreased strength in RLE [MASKED] pain; otherwise grossly intact DISCHARGE EXAM: ---------------- VS: 97.8, 134/70, 65, 16, 99% RA FSBG: 179-244 last 24 hours I/O: 100/500 last 8 hours; 1260/550+ last 24 hours Last BM: recorded as [MASKED] per patient had BM 2 days ago GEN: alert, appropriately interactive; making appropriate eye contact during conversation; pleasant, in NAD HEENT: white haired, bearded, glasses on, MMM; +tongue fasciculations Neck: supple CV: RRR, no m/r/g PULM: CTAB without crackles, rhonchi, or wheezes anteriorly and laterally ABD: Soft, ND, NTTP, no r/g, BS+ EXT: Warm well perfused, no edema; minimal pain with palpation of RLE. Mild discomfort with palpation of lateral aspect of R leg; Low frequency resting pill-rolling tremor in RUE NEURO: A&Ox3, asking why he is in the hospital but no apparent focal deficits Pertinent Results: ADMISSION LABS: ---------------- [MASKED] 08:45PM BLOOD WBC-7.3 RBC-2.94* Hgb-8.1* Hct-24.5* MCV-83 MCH-27.6 MCHC-33.1 RDW-18.0* RDWSD-53.6* Plt [MASKED] [MASKED] 08:45PM BLOOD Neuts-87.7* Lymphs-5.7* Monos-5.6 Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-6.43* AbsLymp-0.42* AbsMono-0.41 AbsEos-0.01* AbsBaso-0.01 [MASKED] 08:45PM BLOOD Glucose-248* UreaN-25* Creat-1.1 Na-132* K-4.8 Cl-97 HCO3-26 AnGap-14 OTHER IMPORTANT LABS: [MASKED] 12:45AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 12:45AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 12:45AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 06:20PM URINE CastGr-3* CastHy-6* [MASKED] 06:20PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [MASKED] 06:20PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 10:29PM URINE CastGr-1* CastHy-20* [MASKED] 10:29PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 10:29PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [MASKED] 06:20PM URINE Hours-RANDOM UreaN-514 Creat-120 Na-45 K-47 Cl-42 Phos-74.6 [MASKED] 06:20PM URINE Osmolal-430 [MASKED] 10:30PM URINE Hours-RANDOM Na-30 K-58 Cl-21 [MASKED] 10:30PM URINE Osmolal-473 MICROBIOLOGY: -------------- [MASKED] HSV 1 and 2 Direct Antigen Test: Negative [MASKED] Varicella Zoster Virus Direct Antigen Test: Negative [MASKED] Urine Culture: Negative [MASKED] Urine Culture: Negative IMAGING: --------- [MASKED] Knee [MASKED]: No acute fracture or dislocation. [MASKED] Hip [MASKED]: No acute fracture or dislocation. Lucent right acetabular lesion not clearly visualized. If strong concern for fracture, CT advised. [MASKED] CT Lower Extremity: A large lytic lesion in the right acetabulum concerning for metastatic disease has slightly increased in size. There is cortical breakthrough as described above but no acute superimposed fracture or dislocation. [MASKED] CT Lower Extremity (Repeat to capture lower leg): There is a right hemi sacral fracture with extension into the S1 neural foramen. Again seen is a 4.2 x 4.4 cm lytic lesion in the superior right acetabulum with apparent extension into the gluteus minimus. Given areas of cortical penetration, an underlying pathologic fracture is not excluded. [MASKED] CT Head without Contrast: Multiple areas of edema at compatible with known brain metastases. No evidence of new lesions although noncontrast CT has limited sensitivity. There is no evidence of hemorrhage. No change since the head CT of [MASKED]. [MASKED] CT Head without Contrast: No acute intracranial abnormality on noncontrast head CT. Edema in the right frontal lobe and right cerebellar hemisphere compatible with known metastatic disease, similar to prior exam. Other supratentorial and infratentorial metastatic disease is better assessed on the recent MR. [MASKED] LABS: ---------------- None Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o man with PMHx [MASKED], HTN, HLD, and recent diagnosis of Stage IV NSCLC with brain mets s/p Cyberknife. He was recently admitted after fall and found to have large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough and completed XRT to this region as well on [MASKED]. He was re-admitted 5 days later w/ recurrent mechanical fall at home and exacerbation of R leg pain. ACTIVE PROBLEMS: ------------------ # Right Acetabular Metastases: The patient has had significant RLE pain since prior admission due to known acetabular bony metastases. He completed 5 fractions of XRT on [MASKED], with what appeared to transient improvement in his sx while at home. Prior to re-admission, however, he did, per his wife, begin to have recurring pain, which likely contributed to his fall. During this admission, he had imaging showing largely stable bony mets and was initially managed conservatively with pain medications. Per radiation oncology, he would not be candidate and would not likely benefit from further XRT. He was taken by [MASKED] on [MASKED] for cryoablation of R acetabular mets with cementoplasty with eventual improvement in his symptoms. He tolerated the procedure well and was slowly weaned off opiod medications. Prior to discharge, he was able to ambulate small distances with assistance of [MASKED]. # Somnolence likely [MASKED] Hypoactive Toxic-Metabolic Encephalopathy: During this admission, the patient triggered upon being found to be somnolent. He was without any focal neuro deficits, vital signs were within normal limits, and fingerstick blood sugars were normal. Most likely explanation for this acute event was felt to be likely hypoactive delirium in the setting of recent changes in oxycontin dosage and dexamethasone frequency, perhaps with resultant disturbance in sleep-wake cycle. Other considerations included acute intracranial bleed, not visualized on CT Head NC, and seizure. The patient quickly recovered with rapid improvement in mentation. Neuro-oncology was consulted, who did not feel keppra or further work-up for seizure to be indicated. They also recommended continuing the same dosage of dexamethasone pending repeat Brain MRI and neuro-oncology follow up. # Acute Toxic Metabolic Encephalopathy: The patient had acute, waxing-waning mental status changes during this admission. This was also present during his last admission, and was again likely due to combination of pain from his metastatic lesions, sedating medications (mostly opiods), and other metabolic disturbances such as [MASKED] and constipation. With largely treatment of his RLE metastatic lesions with cryo-ablation and cementoplasty and management of his pain, his mental status began to clear. Infection and new, primary CNS process was ruled out given his recent history of UTI and known history of intra-cranial mets. Prior to discharge, Mr. [MASKED] was consistently [MASKED] at his baseline. # Fall due to baseline gait instability/deconditioning: Per patient, he appeared to have suffered a mechanical fall [MASKED] pain and compromised balance I/s/o known [MASKED] Disease and deconditioning (multiple recent hospitalizations). He denied any signs of syncope or seizure or antecendent symptoms suggestive of alternate etiology. He denied any injuries or head strike and imaging [MASKED] in ED w/o fracture as above. CT Head was also unremarkable for any new intracranial abnormalities. His pain was managed as above and he worked closely with [MASKED] throughout this admission prior to ultimate discharge to rehab. # Stage IV NSCLC: The overall plan for Mr. [MASKED] had been to resume chemotherapy after his clinical condition had stabilized, following his most recent admission. This re-admission further delayed chemotherapy and ultimately, his goals of care shifted based on multiple family meetings held during this hospitalization between the patient, his primary team, and palliative care. As he was not felt to be safe at home due to his baseline gait instability and weakness, the patient was discharged to short term rehab with goal of transitioning to home and possibility of hospice thereafter. CHRONIC/STABLE/RESOLVED PROBLEMS: # HSV Dermatitis: The patient developed a small herpetiform rash c/w HSV dermatitis around his sacrum and was treated empirically with 7 days of PO acyclovir with good effect. # [MASKED] due to pre-renal azotemia/Stage II CKD: The patient presented with Cr of 1.1, at baseline, c/w stage II CKD. During this admission, amidst waxing and waning mentation with subsequent poor PO intake, his Cr rose to 1.4. With IVF and encouraged PO, his Cr returned back to baseline. # [MASKED] Disease: The patient was continued on his home dose of Carbidopa/Levadopa during this hospitalization. # Type 2 Diabetes Mellitus: The patient was continued on his home lantus and ISS on admission. This was adjusted due to poor PO intake initially and subsequently re-adjusted for rising FSBG's in the setting of increased steroid dosage. TRANSITIONAL ISSUES: -Per multiple family meetings held during this admission and concerns about medical safety in the home setting, the patient was discharged to short term rehab, with hopes for possible transition to home. -Should patient not be able to come home, consider evaluation for long term placement and/or initiation of hospice services at that time -The patient's steroid dosage for cerebral edema [MASKED] intra-cranial metastases was increased from 2mg PO q24H to 2mg PO q12H. Per Neuro-oncology, the patient was maintained on this dosage on discharge and would need repeat Head MRI and Neuro-Oncology follow-up to decide further steroid regimen. -The patient should follow-up with his primary oncologist regarding setting up any Neuro-Oncology appointments as needed and for further management of his cancer overall -Patient was treated with 7-day course of PO acyclovir for recurrent, local HSV dermatitis (R lumbar back) -Given patient's underlying [MASKED] Disease, the patient should not be given any first-generation anti-psychotic medications or anti-dopaminergic agents -CODE STATUS: DNR/DNI -Contact Information for Primary Oncologist: [MASKED] ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears 2 DROP BOTH EYES TID 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa ([MASKED]) 1 TAB PO Q5PM 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. Sertraline 25 mg PO DAILY 11. Vitamin D 5000 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q8H:PRN pain 13. Dexamethasone 2 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 15. Polyethylene Glycol 17 g PO TID 16. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Artificial Tears 2 DROP BOTH EYES TID 3. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa ([MASKED]) 1 TAB PO Q5PM 5. Dexamethasone 2 mg PO Q12H 6. Docusate Sodium 100 mg PO BID 7. Donepezil 5 mg PO QHS 8. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 17.2 mg PO QHS:PRN constipation 12. Sertraline 25 mg PO DAILY 13. Ibuprofen 400 mg PO Q8H 14. Omeprazole 20 mg PO DAILY 15. Atorvastatin 40 mg PO QPM 16. FoLIC Acid 1 mg PO DAILY 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: -Metastatic Non-Small Cell Lung Cancer -Mechanical Fall due to Baseline Gait Instability and Prolonged Deconditioning SECONDARY DIAGNOSIS/ES: -Acute Toxic-Metabolic Encephalopathy -Hemisacral Fracture due to Fall -Metastatic Brain Lesions due to NSCLC and associated Cerebral Edema -Recurrent, Local Herpes Simplex Virus Dermatitis -Acute Kidney Injury due to Pre-Renal Azotemia -Stage 2 Chronic Kidney Disease -[MASKED] Disease -Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you felt weak and fell at home. On admission, you were also in a lot of pain from the cancer in your right leg as well as from your fall. You were given medications to help with your pain. You also underwent a procedure to remove some of the cancer in your leg and stabilize the bone. Your pain improved significantly after this procedure and you were even starting to walk with physical therapy. During this hospitalization, we also held a family meeting with you, your wife, and doctors from multiple [MASKED] in the hospital to discuss your overall goals of care. It was felt that you would most benefit from being in a place where you could have supported care 24 hours a day, which you would not be able to receive at home. As such, you were discharged to short term rehab to work on your strength and hopefully be able to transition you back home. Please take note of the changes in your home medications and follow up with your outpatient doctors [MASKED] detailed in the rest of your discharge paperwork). Thank you for allowing us to be a part of your care, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "E785", "Z794", "I129", "N400", "Z87891", "K5900", "Z66" ]
[ "C7951: Secondary malignant neoplasm of bone", "G936: Cerebral edema", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "S3210XA: Unspecified fracture of sacrum, initial encounter for closed fracture", "C7931: Secondary malignant neoplasm of brain", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "S7001XA: Contusion of right hip, initial encounter", "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "R442: Other hallucinations", "G8911: Acute pain due to trauma", "G893: Neoplasm related pain (acute) (chronic)", "M25551: Pain in right hip", "W860XXA: Exposure to domestic wiring and appliances, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "W1839XA: Other fall on same level, initial encounter", "Z9181: History of falling", "Z923: Personal history of irradiation", "G20: Parkinson's disease", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "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)", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z87891: Personal history of nicotine dependence", "M5137: Other intervertebral disc degeneration, lumbosacral region", "L130: Dermatitis herpetiformis", "Z7952: Long term (current) use of systemic steroids", "K5900: Constipation, unspecified", "Z66: Do not resuscitate", "R4181: Age-related cognitive decline", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "G4753: Recurrent isolated sleep paralysis", "I951: Orthostatic hypotension", "Z87440: Personal history of urinary (tract) infections", "R2681: Unsteadiness on feet" ]
10,063,444
26,443,189
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 was trying to get my girlfriend's attention." Major Surgical or Invasive Procedure: None History of Present Illness: For further details of the history and presentation, please see ___, including Dr. ___ initial consultation note dated ___, Dr. ___ initial consultation note dated ___, and admission note by Dr. ___ dated ___. . Briefly, this is a ___ year old man with no formal medical or psychiatric history who presented to ___ via EMS s/p suicide attempt via hanging. On initial interview, patient reported his problems began approximately 3 months ago in the setting of conflict with his then girlfriend. On the ___ prior to presentation, he found out his ex-girlfriend has a new boyfriend, which made him very upset. Reported suicidal ideation every day over the past week with difficulty sleeping for the first two days. On the night prior to presentation he realized his ex-girlfriend ___ want to talk to him anymore, which triggered thoughts of using a belt to hang himself. Reported feeling relieved when his ex-girlfriend's brother saved him, immediately thinking of his 6 month old son, stating he cried. Patient reported insomnia for approximately 2 days on the week prior admission in addition to decreased appetite, low mood, hopelessness. . Per collateral obtained by his ex-girlfriend's brother ___ ___: ___: Mr. ___ reports that patient has been "having a hard time" over the past few days, since breakup with his girlfriend. The patient lives in the same home as his now ex-girlfriend, her two brothers, one of whom is providing this collateral, and his ex-girlfriend's parents. Patient also has a 7 month old baby with his ex-girlfriend, who is also in the home with them. . Mr. ___ reports that last night, the patient began saying "that he can't do it anymore and that he wants to die." Patient reportedly "mentioned that he thought of taking pills and hanging himself". Within the next hour, patient allegedly said that "he's done and he can't do this." Patient went to the bottom floor of the house. Mr. ___ went downstairs to check on the patient some minutes later and found him hanging with a belt around his neck. Ex-girlfriend's other brother came downstairs and cut the belt off. The patient then fell to the floor and was conscious. At that time, Mr. ___ went upstairs to check on the baby. While he was doing this, the patient got dressed and left the house. . At that time, patient's ex-girlfriend called ___. Mr. ___ reports that nothing like this has happened before, to his knowledge, and that he has never heard the patient make suicidal statements before. He is unsure of the patient's mental health history. He reports that the patient does not drink or use any illicit drugs. When asked if he is concerned for the patient's safety, he states, "This all just happened so fast, I'm not really sure what to think of it yet." . ED Course: patient was in good behavioral control and did not require physical or chemical restraints . On my interview with Mr. ___, who was calm and cooperative but tended to minimize the presentation, he denied feeling depressed until approximately a week prior to presentation. Patient stated, "let me tell you what happened... I met my girlfriend ___ years ago and when we met I was talking with multiple girls." Patient stated he became exclusive with his girlfriend but met another girl whom he had been talking with on social media coincidentally at work. Stated that 6 months into his relationship with his girlfriend he had told this other woman that she looked nice and asked her if she wanted to hang out and that she texted back "yes." However, patient stated he never replied back to this girl and that nothing further happened with this other woman. . Patient reported that "everything was perfect" with his girlfriend, with whom he has a ___ year old son with, but that about 3 months ago his girlfriend went "way back" looking at his text messages and found this text message from this other woman. Mr. ___ reported that she became angry, stating that she did not want to be with him and that he told her he was going to do whatever he needed to in order to "make it right." Reported he felt things were going "okay" until he started going through her phone about 2 weeks ago, stating he found out that she had been cheating on him. . Patient stated that he became very distraught but denied suicidal ideation, stating he only attempted to hang himself in order to "get her attention." However, denies persistently depressed mood, poor energy, concentration, poor appetite, current suicidal ideation or thoughts of self harm. Reported that since his admission he has talked with his girlfriend and he plans on moving out of the house "and work things out with time." . Patient reports good sleep at night, stating he sleeps about 9 hours per night. Denied anhedonia, stating he enjoys being with his son, who is 6 months. Denies difficulty with energy. On psychiatric review of systems, denies history of manic symptoms including decreased need for sleep, increased energy, grandiosity. Denies anxiety, panic attacks. Denies history of psychosis including AVH, paranoia, TIB. Denies alcohol or drug use. Past Medical History: Past Psychiatric History: - Diagnoses: no formal psychiatric diagnoses - SA/SIB: see HPI - Hospitalizations: none - Psychiatrist: none - Therapist: none - Medication Trials: none Past Medical History: Denies Social History: Substance History: - Alcohol: denies - Illicits: denies - Tobacco: denies . Social History: ___ Family History: - Diagnoses: denies, but aunt was reportedly hospitalized at ___ after "freaking out" - Suicides: denies - Addictions: denies Physical Exam: ___ 1653 Temp: 98.2 PO BP: 123/83 HR: 98 RR: 16 O2 sat: 100% Gen: NAD, normal posture, well-nourished, appears his stated age, with good hygiene and grooming HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. Neck: Supple. No LAD. No masses or goiter. Trachea midline. CV: Regular rate, positive S1, S2, no gross murmurs/rubs/gallops. Chest: Clear to ausculation bilaterally Abdomen: Soft, non-tender, non-distended. Positive BS. Ext: Warm and well-perfused, no edema. Skin: Scars, tatoos Neuro: Cranial nerves ___ symmetrically intact. Motor: Normal bulk and tone, no tremor, or bradykinesia. Full strength in bilateral deltoids, elbow flexion and extension, finger flexion, hip flexors, knee flexion and extension. Coord: Finger-nose-finger movements intact. No truncal ataxia. ___: grossly intact Gait: Posture, stride, and arm-swing normal. Neuropsychiatric Examination: Behavior: cooperative/engaged, calm with good eye contact *Mood and Affect: "stressed" and congruent; reactive; nonlabile; appropriate to situation *Thought process : linear and goal directed. No loosening of associations, no tangentiality. Does not appear to be responding to internal stimuli. *Thought Content : Denies any HI or Suicidal intent. No AVH. No overt paranoia or delusions. Insight: Poor Judgement: Questionable Cognition: -Orientation: Full (Name, Place and Time/Date). -Attention: Can spell "WORLD" backwards -Memory: intact to history; ___ registration and ___ spontaneous with remaining word elicited with categorical prompting at 3-minute recall -Fund of knowledge: Average -Calculations: $1.75= 7 quarters -Abstraction: concrete watch/ruler: Numbers, apple/orange: Same size, train/bus: Transportation Proverb "the grass is always greener on the other side": "Good things can happen" -Speech: Normal rate, rhythm, volume, prosody. Demonstrates appropriate variation in tone. -Language: Fluent ___ with slight accent without paraphasic errors Pertinent Results: ___: Na: 141 ___: K: 4.9 ___: Cl: 103 ___: CO2: 24 ___: BUN: 15 ___: Creat: 1.1 ___: Glucose: 102* ___: WBC: 5.7 ___: RBC: 5.25 ___: HGB: 14.1 ___: HCT: 43.1 ___: MCV: 82 ___: MCH: 26.9 ___: MCHC: 32.7 ___: RDW: 13.3 ___: Plt Count: 245 ___: Neuts%: 69.2 ___: Lymphs: 23.0 ___: MONOS: 7.2 ___: Eos: 0.2* ___: BASOS: 0.2 ___: AbsNeuts: 3.9 ___: Benzodiazepine: NEG ___: Barbiturate: NEG ___: Opiate: NEG ___: Cocaine: NEG ___: Amphetamine: NEG ___: Methadone: NEG Brief Hospital Course: This is a ___ year old man with no formal medical or psychiatric history who presented to ___ via EMS s/p suicide attempt via hanging. Upon interview, patient reported he was doing well and was in his usual state of health until approximately 1.5 weeks ago after he found out his girlfriend and mother of his ___ month old child was cheating on him. In this setting, patient reported he became acutely distraught with 2 days of insomnia, low mood, poor appetite, attempting to hang himself with a belt in his house which he shares with his girlfriend and her family. On my interview, patient currently denies depressed mood, anxiety, NVS on examination and states that his suicide attempt was a means to obtain his girlfriend's attention. MSE notable for a well groomed, cooperative man with good eye contact, denial of all depressive symptoms and thought process that is notably linear, logical, goal and future oriented. . Diagnostically, etiology of presentation seems most consistent with adjustment disorder with depressed mood with improvement of depression in the setting of reported resolution of conflict with his girlfriend. No evidence on my examination to suggest a current depressive episode-- he is not dysthymic or dysphoric on examination, although I am concerned he may be minimizing his current symptoms, and appears euthymic. Denies symptoms of anxiety and denies SI or thoughts of self harm. Nothing in his history to suggest a history of manic symptoms and he is certainly not manic on my examination. Denies history of psychotic symptoms and nothing on examination that is concerning for acute psychosis. Given young age and good health, underlying medical condition is unlikely to be playing a role in his presentation. Likewise, given denial of substance use and negative tox screen, I do not believe that alcohol or substance use is a factor in his presentation. . #. Legal/Safety Patient admitted to ___ on a section 12a, upon admission, patient declined to sign a CV and remained on section 12b status throughout his stay. Patient maintained his safety throughout his hospitalization on 15 minute checks and did not require physical or chemical restraints. Given consistent denial of SI, thoughts of self harm with no evidence that he represented an acute risk to himself or others, I did not feel he met criteria to file a 7&8b and he was discharged upon expiration of his ___. . #. Adjustment Disorder with Depressed Mood - patient declined medications on admission. He was offered hydroxyzine for anxiety, which he did not utilize. He was willing to engage with the team, and attended group therapy sessions which focused on development of coping skills and psychoeducation, and expressed an interest in outpatient therapy following discharge. He consistently denied suicidal ideation, intent, or plan throughout his stay, and he was future-oriented, and engaged with both psychiatry and social work. - Collateral obtained on the day of discharge from his girlfriend's brother, who he was living with: patient appeared to have returned to his baseline, looked well, and was engaged in planning for his future and the care of his son. Noted that nobody in the family had acute concerns for his safety, and that they looked forward to him returning home . #. Medical: No acute issues during this hospitalization Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: Patient was not taking any medications at the time of discharge Discharge Disposition: Home Discharge Diagnosis: Adjustment disorder Discharge Condition: VS: T 98.5 PO | BP 138 / 85 | HR 68 | RR 17 | SpO2: 100% on RA Alert and Oriented, Clear and Coherent Ambulatory Status: Independent station and gait: normal station with normal stable gait tone and strength: moves all extremities freely antigravity cranial nerves: grossly intact abnormal movements: none observed Appearance: age appearing black man, appropriate grooming, casual clothing Behavior: pleasant and cooperative, appropriate eye contact Mood and Affect: 'good'/ congruent, euthymic Thought process: Linear and goal directed, no LOA Thought Content: Denies SI/HI, does not disclose AVH, not responding to internal stimuli Speech: regular rate and rhythm, appropriate volume and variation in tone Language: fluent ___ without errors Judgment and Insight: 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: ___
[ "F4320", "R45851" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I was trying to get my girlfriend's attention." Major Surgical or Invasive Procedure: None History of Present Illness: For further details of the history and presentation, please see [MASKED], including Dr. [MASKED] initial consultation note dated [MASKED], Dr. [MASKED] initial consultation note dated [MASKED], and admission note by Dr. [MASKED] dated [MASKED]. . Briefly, this is a [MASKED] year old man with no formal medical or psychiatric history who presented to [MASKED] via EMS s/p suicide attempt via hanging. On initial interview, patient reported his problems began approximately 3 months ago in the setting of conflict with his then girlfriend. On the [MASKED] prior to presentation, he found out his ex-girlfriend has a new boyfriend, which made him very upset. Reported suicidal ideation every day over the past week with difficulty sleeping for the first two days. On the night prior to presentation he realized his ex-girlfriend [MASKED] want to talk to him anymore, which triggered thoughts of using a belt to hang himself. Reported feeling relieved when his ex-girlfriend's brother saved him, immediately thinking of his 6 month old son, stating he cried. Patient reported insomnia for approximately 2 days on the week prior admission in addition to decreased appetite, low mood, hopelessness. . Per collateral obtained by his ex-girlfriend's brother [MASKED] [MASKED]: [MASKED]: Mr. [MASKED] reports that patient has been "having a hard time" over the past few days, since breakup with his girlfriend. The patient lives in the same home as his now ex-girlfriend, her two brothers, one of whom is providing this collateral, and his ex-girlfriend's parents. Patient also has a 7 month old baby with his ex-girlfriend, who is also in the home with them. . Mr. [MASKED] reports that last night, the patient began saying "that he can't do it anymore and that he wants to die." Patient reportedly "mentioned that he thought of taking pills and hanging himself". Within the next hour, patient allegedly said that "he's done and he can't do this." Patient went to the bottom floor of the house. Mr. [MASKED] went downstairs to check on the patient some minutes later and found him hanging with a belt around his neck. Ex-girlfriend's other brother came downstairs and cut the belt off. The patient then fell to the floor and was conscious. At that time, Mr. [MASKED] went upstairs to check on the baby. While he was doing this, the patient got dressed and left the house. . At that time, patient's ex-girlfriend called [MASKED]. Mr. [MASKED] reports that nothing like this has happened before, to his knowledge, and that he has never heard the patient make suicidal statements before. He is unsure of the patient's mental health history. He reports that the patient does not drink or use any illicit drugs. When asked if he is concerned for the patient's safety, he states, "This all just happened so fast, I'm not really sure what to think of it yet." . ED Course: patient was in good behavioral control and did not require physical or chemical restraints . On my interview with Mr. [MASKED], who was calm and cooperative but tended to minimize the presentation, he denied feeling depressed until approximately a week prior to presentation. Patient stated, "let me tell you what happened... I met my girlfriend [MASKED] years ago and when we met I was talking with multiple girls." Patient stated he became exclusive with his girlfriend but met another girl whom he had been talking with on social media coincidentally at work. Stated that 6 months into his relationship with his girlfriend he had told this other woman that she looked nice and asked her if she wanted to hang out and that she texted back "yes." However, patient stated he never replied back to this girl and that nothing further happened with this other woman. . Patient reported that "everything was perfect" with his girlfriend, with whom he has a [MASKED] year old son with, but that about 3 months ago his girlfriend went "way back" looking at his text messages and found this text message from this other woman. Mr. [MASKED] reported that she became angry, stating that she did not want to be with him and that he told her he was going to do whatever he needed to in order to "make it right." Reported he felt things were going "okay" until he started going through her phone about 2 weeks ago, stating he found out that she had been cheating on him. . Patient stated that he became very distraught but denied suicidal ideation, stating he only attempted to hang himself in order to "get her attention." However, denies persistently depressed mood, poor energy, concentration, poor appetite, current suicidal ideation or thoughts of self harm. Reported that since his admission he has talked with his girlfriend and he plans on moving out of the house "and work things out with time." . Patient reports good sleep at night, stating he sleeps about 9 hours per night. Denied anhedonia, stating he enjoys being with his son, who is 6 months. Denies difficulty with energy. On psychiatric review of systems, denies history of manic symptoms including decreased need for sleep, increased energy, grandiosity. Denies anxiety, panic attacks. Denies history of psychosis including AVH, paranoia, TIB. Denies alcohol or drug use. Past Medical History: Past Psychiatric History: - Diagnoses: no formal psychiatric diagnoses - SA/SIB: see HPI - Hospitalizations: none - Psychiatrist: none - Therapist: none - Medication Trials: none Past Medical History: Denies Social History: Substance History: - Alcohol: denies - Illicits: denies - Tobacco: denies . Social History: [MASKED] Family History: - Diagnoses: denies, but aunt was reportedly hospitalized at [MASKED] after "freaking out" - Suicides: denies - Addictions: denies Physical Exam: [MASKED] 1653 Temp: 98.2 PO BP: 123/83 HR: 98 RR: 16 O2 sat: 100% Gen: NAD, normal posture, well-nourished, appears his stated age, with good hygiene and grooming HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. Neck: Supple. No LAD. No masses or goiter. Trachea midline. CV: Regular rate, positive S1, S2, no gross murmurs/rubs/gallops. Chest: Clear to ausculation bilaterally Abdomen: Soft, non-tender, non-distended. Positive BS. Ext: Warm and well-perfused, no edema. Skin: Scars, tatoos Neuro: Cranial nerves [MASKED] symmetrically intact. Motor: Normal bulk and tone, no tremor, or bradykinesia. Full strength in bilateral deltoids, elbow flexion and extension, finger flexion, hip flexors, knee flexion and extension. Coord: Finger-nose-finger movements intact. No truncal ataxia. [MASKED]: grossly intact Gait: Posture, stride, and arm-swing normal. Neuropsychiatric Examination: Behavior: cooperative/engaged, calm with good eye contact *Mood and Affect: "stressed" and congruent; reactive; nonlabile; appropriate to situation *Thought process : linear and goal directed. No loosening of associations, no tangentiality. Does not appear to be responding to internal stimuli. *Thought Content : Denies any HI or Suicidal intent. No AVH. No overt paranoia or delusions. Insight: Poor Judgement: Questionable Cognition: -Orientation: Full (Name, Place and Time/Date). -Attention: Can spell "WORLD" backwards -Memory: intact to history; [MASKED] registration and [MASKED] spontaneous with remaining word elicited with categorical prompting at 3-minute recall -Fund of knowledge: Average -Calculations: $1.75= 7 quarters -Abstraction: concrete watch/ruler: Numbers, apple/orange: Same size, train/bus: Transportation Proverb "the grass is always greener on the other side": "Good things can happen" -Speech: Normal rate, rhythm, volume, prosody. Demonstrates appropriate variation in tone. -Language: Fluent [MASKED] with slight accent without paraphasic errors Pertinent Results: [MASKED]: Na: 141 [MASKED]: K: 4.9 [MASKED]: Cl: 103 [MASKED]: CO2: 24 [MASKED]: BUN: 15 [MASKED]: Creat: 1.1 [MASKED]: Glucose: 102* [MASKED]: WBC: 5.7 [MASKED]: RBC: 5.25 [MASKED]: HGB: 14.1 [MASKED]: HCT: 43.1 [MASKED]: MCV: 82 [MASKED]: MCH: 26.9 [MASKED]: MCHC: 32.7 [MASKED]: RDW: 13.3 [MASKED]: Plt Count: 245 [MASKED]: Neuts%: 69.2 [MASKED]: Lymphs: 23.0 [MASKED]: MONOS: 7.2 [MASKED]: Eos: 0.2* [MASKED]: BASOS: 0.2 [MASKED]: AbsNeuts: 3.9 [MASKED]: Benzodiazepine: NEG [MASKED]: Barbiturate: NEG [MASKED]: Opiate: NEG [MASKED]: Cocaine: NEG [MASKED]: Amphetamine: NEG [MASKED]: Methadone: NEG Brief Hospital Course: This is a [MASKED] year old man with no formal medical or psychiatric history who presented to [MASKED] via EMS s/p suicide attempt via hanging. Upon interview, patient reported he was doing well and was in his usual state of health until approximately 1.5 weeks ago after he found out his girlfriend and mother of his [MASKED] month old child was cheating on him. In this setting, patient reported he became acutely distraught with 2 days of insomnia, low mood, poor appetite, attempting to hang himself with a belt in his house which he shares with his girlfriend and her family. On my interview, patient currently denies depressed mood, anxiety, NVS on examination and states that his suicide attempt was a means to obtain his girlfriend's attention. MSE notable for a well groomed, cooperative man with good eye contact, denial of all depressive symptoms and thought process that is notably linear, logical, goal and future oriented. . Diagnostically, etiology of presentation seems most consistent with adjustment disorder with depressed mood with improvement of depression in the setting of reported resolution of conflict with his girlfriend. No evidence on my examination to suggest a current depressive episode-- he is not dysthymic or dysphoric on examination, although I am concerned he may be minimizing his current symptoms, and appears euthymic. Denies symptoms of anxiety and denies SI or thoughts of self harm. Nothing in his history to suggest a history of manic symptoms and he is certainly not manic on my examination. Denies history of psychotic symptoms and nothing on examination that is concerning for acute psychosis. Given young age and good health, underlying medical condition is unlikely to be playing a role in his presentation. Likewise, given denial of substance use and negative tox screen, I do not believe that alcohol or substance use is a factor in his presentation. . #. Legal/Safety Patient admitted to [MASKED] on a section 12a, upon admission, patient declined to sign a CV and remained on section 12b status throughout his stay. Patient maintained his safety throughout his hospitalization on 15 minute checks and did not require physical or chemical restraints. Given consistent denial of SI, thoughts of self harm with no evidence that he represented an acute risk to himself or others, I did not feel he met criteria to file a 7&8b and he was discharged upon expiration of his [MASKED]. . #. Adjustment Disorder with Depressed Mood - patient declined medications on admission. He was offered hydroxyzine for anxiety, which he did not utilize. He was willing to engage with the team, and attended group therapy sessions which focused on development of coping skills and psychoeducation, and expressed an interest in outpatient therapy following discharge. He consistently denied suicidal ideation, intent, or plan throughout his stay, and he was future-oriented, and engaged with both psychiatry and social work. - Collateral obtained on the day of discharge from his girlfriend's brother, who he was living with: patient appeared to have returned to his baseline, looked well, and was engaged in planning for his future and the care of his son. Noted that nobody in the family had acute concerns for his safety, and that they looked forward to him returning home . #. Medical: No acute issues during this hospitalization Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: Patient was not taking any medications at the time of discharge Discharge Disposition: Home Discharge Diagnosis: Adjustment disorder Discharge Condition: VS: T 98.5 PO | BP 138 / 85 | HR 68 | RR 17 | SpO2: 100% on RA Alert and Oriented, Clear and Coherent Ambulatory Status: Independent station and gait: normal station with normal stable gait tone and strength: moves all extremities freely antigravity cranial nerves: grossly intact abnormal movements: none observed Appearance: age appearing black man, appropriate grooming, casual clothing Behavior: pleasant and cooperative, appropriate eye contact Mood and Affect: 'good'/ congruent, euthymic Thought process: Linear and goal directed, no LOA Thought Content: Denies SI/HI, does not disclose AVH, not responding to internal stimuli Speech: regular rate and rhythm, appropriate volume and variation in tone Language: fluent [MASKED] without errors Judgment and Insight: 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]
[]
[]
[ "F4320: Adjustment disorder, unspecified", "R45851: Suicidal ideations" ]
10,063,460
26,955,151
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: pre-admission for angiogram Major Surgical or Invasive Procedure: ___- diagnostic angiogram History of Present Illness: Mr. ___ presents in preparation for a RLE angiogram. He has ulcers on the lateral aspect of the right TMA. He denies claudication and rest pain. He is on antibiotics for a foot-wound infection. Since starting antibiotics, he reports he has no pain in his foot. He also denies fever/chills. Of note, the patient reports that he thinks that during his last angiogram, his penis pump was punctured. He is requesting this be addressed during this admission if possible. Past Medical History: PAD, type 1 diabetes, kidney transplant, failed pancreas transplant in ___, diabetic retinopathy (legally blind), GERD, hypertension, hyperlipidemia Past Surgical History: - Kidney transplant/failed pancreas transplant ___ (___) - ___ necrotic ___ toe amputation - ___ angioplasty - ___ right foot debridement - ___ TMA/TAL Physical Exam: Admission Physical Exam VS: 98.2 86 165/80 18 96 RA General: overall well-appearing, NAD HEENT: NC/AT Resp: breathing comfortably on room air CV: RRR Abd: Soft, NT/ND Ext: Right foot s/p TMA, ulcers on the medial aspect of the incision and laterally at the met-head, some fibrinous exudate, mild surrounding cellulitis Pulses: Right lower extremity with palpable femoral pulse, strong doppler signal in the ___, weak doppler signal in the DP Discharge physical exam Vitals: T 97.8 BP 133/80 HR 83 RR 18 O2 Sat 95% RA Gen: NAD, A/Ox3 CV: RRR Lungs: CTAB, not in acute distress Abdomen: soft, nontender, non distended , no rebound or guarding Wound: no groin hematoma, C/D/I Extremity: warm, well perfused, no edema, right TMA, with lateral ulcer, no purulence expressed Pulses: R p/d, L d/d Pertinent Results: ___ 12:30AM BLOOD Glucose-157* UreaN-20 Creat-1.2 Na-142 K-4.0 Cl-106 HCO3-26 AnGap-10 ___ 12:30AM BLOOD WBC-6.5 RBC-3.70* Hgb-9.8* Hct-31.5* MCV-85 MCH-26.5 MCHC-31.1* RDW-14.4 RDWSD-44.5 Plt ___ Brief Hospital Course: Mr. ___ is a ___ M w/ PMH DM, ESRD s/p renal and pancreas transplant ( ___ and right TMA in ___ of this year, who presents to ___ as a pre-admission for an angiogram. The patient was taken to the endovascular suite on ___ and underwent a diagnostic angiogram. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Patient is well known by the podiatry service, who were consulted during this admission for his right TMA. They recommended no further debridement at this time, daily betadine with dry gauze dressing changes. Urology was consulted for the questionable penis pump function, who recommended follow up with his outpatient urologist to assess the function Post-operatively, he did well without any groin swelling. He was able to tolerate a regular diet, get out of bed and ambulate with assistance, void without issues, and pain was controlled on oral medications alone. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. Methylprednisolone 4 mg PO 3X/WEEK (___) 6. Methylprednisolone 2 mg PO 4X/WEEK (___) 7. Mycophenolate Mofetil 500 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN Constipation - First Line 10. Sulfameth/Trimethoprim DS 1 TAB PO BID 11. Tacrolimus 2 mg PO Q12H 12. Atorvastatin 80 mg PO DAILY 13. NPH 26 Units Breakfast NPH 14 Units Dinner Regular 10 Units Breakfast Regular 10 Units Lunch Regular 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 14. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Medications: 1. NPH 26 Units Breakfast NPH 14 Units Dinner Regular 10 Units Breakfast Regular 10 Units Lunch Regular 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO DAILY 6. Methylprednisolone 4 mg PO 3X/WEEK (___) 7. Methylprednisolone 2 mg PO 4X/WEEK (___) 8. Mycophenolate Mofetil 500 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Senna 8.6 mg PO BID:PRN Constipation - First Line 11. Tacrolimus 2 mg PO Q12H 12. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: peripheral vascular disease right TMA wound Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___ It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after a peripheral angiogram. To do the test, a small puncture was made in one of your arteries. The puncture site heals on its own: there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Puncture Site Care For one week: •Do not take a tub bath, go swimming or use a Jacuzzi or hot tub. •Use only mild soap and water to gently clean the area around the puncture site. •Gently pat the puncture site dry after showering. •Do not use powders, lotions, or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one-two weeks. TMA wound care: Daily betadine with dry gauze Activity For the first 48 hours: •Do not drive for 48 hours after the procedure For the first week: •Do not lift, push , pull or carry anything heavier than 10 pounds •Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing, sneezing, or moving your bowels. After one week: •You may go back to all your regular activities, including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! Please take Aspirin 81 mg daily For Problems or Questions: Call ___ in an emergency such as: •Sudden, brisk bleeding or swelling at the groin puncture site that does not stop after applying pressure for ___ minutes •Bleeding that is associated with nausea, weakness, or fainting. Call the vascular surgery office (___) right away if you have any of the following. (Please note that someone is available 24 hours a day, 7 days a week) •Swelling, bleeding, drainage, or discomfort at the puncture site that is new or increasing since discharge from the hospital •Any change in sensation or temperature in your legs •Fever of 101 or greater •Any questions or concerns about recovery from your angiogram Best Wishes, Your ___ Vascular Surgery Team Followup Instructions: ___
[ "E1051", "T8743", "L97518", "T86891", "Z940", "T83490A", "Z794", "E10621", "I70235", "E10319", "K219", "I10", "E7849", "Y92018", "Y838" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: pre-admission for angiogram Major Surgical or Invasive Procedure: [MASKED]- diagnostic angiogram History of Present Illness: Mr. [MASKED] presents in preparation for a RLE angiogram. He has ulcers on the lateral aspect of the right TMA. He denies claudication and rest pain. He is on antibiotics for a foot-wound infection. Since starting antibiotics, he reports he has no pain in his foot. He also denies fever/chills. Of note, the patient reports that he thinks that during his last angiogram, his penis pump was punctured. He is requesting this be addressed during this admission if possible. Past Medical History: PAD, type 1 diabetes, kidney transplant, failed pancreas transplant in [MASKED], diabetic retinopathy (legally blind), GERD, hypertension, hyperlipidemia Past Surgical History: - Kidney transplant/failed pancreas transplant [MASKED] ([MASKED]) - [MASKED] necrotic [MASKED] toe amputation - [MASKED] angioplasty - [MASKED] right foot debridement - [MASKED] TMA/TAL Physical Exam: Admission Physical Exam VS: 98.2 86 165/80 18 96 RA General: overall well-appearing, NAD HEENT: NC/AT Resp: breathing comfortably on room air CV: RRR Abd: Soft, NT/ND Ext: Right foot s/p TMA, ulcers on the medial aspect of the incision and laterally at the met-head, some fibrinous exudate, mild surrounding cellulitis Pulses: Right lower extremity with palpable femoral pulse, strong doppler signal in the [MASKED], weak doppler signal in the DP Discharge physical exam Vitals: T 97.8 BP 133/80 HR 83 RR 18 O2 Sat 95% RA Gen: NAD, A/Ox3 CV: RRR Lungs: CTAB, not in acute distress Abdomen: soft, nontender, non distended , no rebound or guarding Wound: no groin hematoma, C/D/I Extremity: warm, well perfused, no edema, right TMA, with lateral ulcer, no purulence expressed Pulses: R p/d, L d/d Pertinent Results: [MASKED] 12:30AM BLOOD Glucose-157* UreaN-20 Creat-1.2 Na-142 K-4.0 Cl-106 HCO3-26 AnGap-10 [MASKED] 12:30AM BLOOD WBC-6.5 RBC-3.70* Hgb-9.8* Hct-31.5* MCV-85 MCH-26.5 MCHC-31.1* RDW-14.4 RDWSD-44.5 Plt [MASKED] Brief Hospital Course: Mr. [MASKED] is a [MASKED] M w/ PMH DM, ESRD s/p renal and pancreas transplant ( [MASKED] and right TMA in [MASKED] of this year, who presents to [MASKED] as a pre-admission for an angiogram. The patient was taken to the endovascular suite on [MASKED] and underwent a diagnostic angiogram. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Patient is well known by the podiatry service, who were consulted during this admission for his right TMA. They recommended no further debridement at this time, daily betadine with dry gauze dressing changes. Urology was consulted for the questionable penis pump function, who recommended follow up with his outpatient urologist to assess the function Post-operatively, he did well without any groin swelling. He was able to tolerate a regular diet, get out of bed and ambulate with assistance, void without issues, and pain was controlled on oral medications alone. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. Methylprednisolone 4 mg PO 3X/WEEK ([MASKED]) 6. Methylprednisolone 2 mg PO 4X/WEEK ([MASKED]) 7. Mycophenolate Mofetil 500 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN Constipation - First Line 10. Sulfameth/Trimethoprim DS 1 TAB PO BID 11. Tacrolimus 2 mg PO Q12H 12. Atorvastatin 80 mg PO DAILY 13. NPH 26 Units Breakfast NPH 14 Units Dinner Regular 10 Units Breakfast Regular 10 Units Lunch Regular 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 14. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Medications: 1. NPH 26 Units Breakfast NPH 14 Units Dinner Regular 10 Units Breakfast Regular 10 Units Lunch Regular 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO DAILY 6. Methylprednisolone 4 mg PO 3X/WEEK ([MASKED]) 7. Methylprednisolone 2 mg PO 4X/WEEK ([MASKED]) 8. Mycophenolate Mofetil 500 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Senna 8.6 mg PO BID:PRN Constipation - First Line 11. Tacrolimus 2 mg PO Q12H 12. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: peripheral vascular disease right TMA wound Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED] It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted to the hospital after a peripheral angiogram. To do the test, a small puncture was made in one of your arteries. The puncture site heals on its own: there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Puncture Site Care For one week: •Do not take a tub bath, go swimming or use a Jacuzzi or hot tub. •Use only mild soap and water to gently clean the area around the puncture site. •Gently pat the puncture site dry after showering. •Do not use powders, lotions, or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one-two weeks. TMA wound care: Daily betadine with dry gauze Activity For the first 48 hours: •Do not drive for 48 hours after the procedure For the first week: •Do not lift, push , pull or carry anything heavier than 10 pounds •Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing, sneezing, or moving your bowels. After one week: •You may go back to all your regular activities, including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! Please take Aspirin 81 mg daily For Problems or Questions: Call [MASKED] in an emergency such as: •Sudden, brisk bleeding or swelling at the groin puncture site that does not stop after applying pressure for [MASKED] minutes •Bleeding that is associated with nausea, weakness, or fainting. Call the vascular surgery office ([MASKED]) right away if you have any of the following. (Please note that someone is available 24 hours a day, 7 days a week) •Swelling, bleeding, drainage, or discomfort at the puncture site that is new or increasing since discharge from the hospital •Any change in sensation or temperature in your legs •Fever of 101 or greater •Any questions or concerns about recovery from your angiogram Best Wishes, Your [MASKED] Vascular Surgery Team Followup Instructions: [MASKED]
[]
[ "Z794", "K219", "I10" ]
[ "E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "T8743: Infection of amputation stump, right lower extremity", "L97518: Non-pressure chronic ulcer of other part of right foot with other specified severity", "T86891: Other transplanted tissue failure", "Z940: Kidney transplant status", "T83490A: Other mechanical complication of implanted penile prosthesis, initial encounter", "Z794: Long term (current) use of insulin", "E10621: Type 1 diabetes mellitus with foot ulcer", "I70235: Atherosclerosis of native arteries of right leg with ulceration of other part of foot", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E7849: Other hyperlipidemia", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure" ]
10,063,460
27,699,140
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Necrotic toe, fevers Major Surgical or Invasive Procedure: ___ necrotic ___ toe amputation ___ angioplasty ___ right foot debridement ___ TMA/TAL History of Present Illness: ___ with type 1 DM c/b ESRD s/p renal/pancreas transplant in ___ (___) w/ failed pancreas transplant w/in ___, presenting from prison due to worsening third right toe infection with gangrene and surrounding erythema. Per note from ___ facility, patient with dry gangrene on right third toe wound. XRay at facility showed no gas or evidence of osteomyelitis. Per nursing report at his facility, they noticed increased erythema surrounding wound and now with drainage noted during dressing changes. Patient reports his symptoms began about one month ago. He reports that he repeatedly requested antibiotics and pain medications but was denied both until today. Past Medical History: Right foot wound Type I DM Kidney transplant/failed pancreas transplant ___ (___) Proliferative diabetic retinopathy, legally blind (R eye blind, L eye 200/20 vision) GERD w/o esophagitis HTN HLD Social History: ___ Family History: Unaware of any renal disease or diabetes in the family Physical Exam: Admission Exam ================== VS: Temp 98.7 F PO 151/95 RR 98 RR 17 96% RA FSBG 265 General: Alert, oriented, no acute distress HEENT: No pallor. no icterus. Milky right eye, blind. Left eye sclera anicteric, no conjunctiva injection. CV: Regular rate and rhythm, normal S1 + S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present. No allograft tenderness. Ext: No edema. Right foot is bandaged. DP and ___ on left foot faintly palpable, warm, no sensation, no lesion. Right foot warm, dopplerable pluses, moving toes, no sensation, dressed c/d/I. Neuro: No asterixis Discharge Exam ================== VS: T 98.5 PO BP 110/70 HR 97 SpO2 98 RA General: Alert, NAD. HEENT: Cloudy right eye, blind. No icterus or injection. MMM. CV: Regular pulse. Resp: Non-labored. Abdomen: Soft, NDNT. Ext: Warm, no edema. Right foot in multipodus boot. Dressing CDI. Surgical site is well coapted w/ sutures intact to R TMA site as well as TAL site. No local signs of dehiscence or infection. Pertinent Results: ADMISSION LABS: ==================== ___ 09:30AM BLOOD WBC-9.5 RBC-4.26* Hgb-11.7* Hct-36.8* MCV-86 MCH-27.5 MCHC-31.8* RDW-13.0 RDWSD-40.4 Plt ___ ___ 09:30AM BLOOD Neuts-72.2* Lymphs-14.8* Monos-11.5 Eos-0.5* Baso-0.2 Im ___ AbsNeut-6.86* AbsLymp-1.41 AbsMono-1.09* AbsEos-0.05 AbsBaso-0.02 ___ 09:30AM BLOOD Plt ___ ___ 09:30AM BLOOD ___ PTT-27.7 ___ ___ 09:30AM BLOOD Glucose-386* UreaN-11 Creat-1.0 Na-136 K-4.1 Cl-92* HCO3-22 AnGap-22* ___ 09:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 ___ 12:30AM BLOOD CRP-146.6* ___ 09:30AM BLOOD tacroFK-4.0* ___ 12:49AM BLOOD Lactate-1.5 DISCHARGE LABS: ======================== ___ 05:25AM BLOOD WBC-8.4 RBC-3.78* Hgb-10.1* Hct-31.8* MCV-84 MCH-26.7 MCHC-31.8* RDW-13.5 RDWSD-41.1 Plt ___ ___ 10:40AM BLOOD Glucose-286* UreaN-13 Creat-0.8 Na-135 K-4.2 Cl-95* HCO3-27 AnGap-13 MICRO: ===================== __________________________________________________________ ___ 10:45 am TISSUE ___ METATARSAL HEAD. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): _______________________________________________________ ___ 9:03 am TISSUE Site: FOOT RIGHT FOOT TISSUE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. _______________________________________________________ ___ BLOOD CULTURE - negative (final) ___ BLOOD CULTURE - negative (final) ___ BLOOD CULTURE - negative (final) ___ BLOOD CULTURE - NGTD PATHOLOGY: ====================== ___ Pathology Tissue: TOES, AMPUTATION, NON-TRAUMATIC 1. ___ toe, right foot, amputation: ___ toe with gangrene necrosis. 2. Margin, ___ toe, right foot, amputation: Trabecular bone with no inflammation identifIed. ___ Pathology Tissue: FOREIGN BODY, GROSS ONLY "Possible foreign body," right foot, excisional debridement: Partially necrotic fibroadipose tissue and blood vessels with extensive calcification along the internal elastic lamina; scant fragments of necrotic bone. Multiple levels examined. ___ Pathology Tissue: TOES, AMPUTATION, NON-TRAUMATIC 1. Toes, right side, amputation: Gangrene 2. Metatarsal heads: One of five bones shows focal acute osteomyelitis (2D, multiple levels examined). 3. Third metatarsal head: Focal acute osteomyelitis. IMAGING & STUDIES: ====================== ___ ARTERIAL U/S (REST ONLY) 1. Significant tibial arterial insufficiency to the lower extremities bilaterally, at rest. 2. Bilateral toe pressures < 30, likely contributing to for wound healing. ___ ANGIOGRAM FINDINGS: 1. Normal caliber abdominal aorta without ectasia or stenosis. 2. Patent bilateral iliac artery systems. 3. Patent right common femoral and profunda femoris arteries. 4. Patent right superficial femoral artery. 5. Patent right popliteal artery. 6. Patent tibial trifurcation. The anterior tibial artery is patent proximally but occludes. The posterior tibial artery is patent to the ankle. The peroneal artery is patent proximally but has several areas of focal stenosis and then lateralizes to the dorsalis pedis at the ankle. 7. At the ankle, the posterior tibial arteries patent and runs off to the foot. The anterior tibial artery is occluded. Following intervention, the peroneal artery is patent to the ankle and collateralizes to the lateral tarsal vessels in the foot. ___ XR FOOT AP,LAT & OBL RIGHT Status post transmetatarsal amputation of all 5 rays, right foot. Subcutaneous gas in the soft tissues posterior to the distal tibia. This may be tracking from the surgical site but correlate for soft tissue defects or signs of soft tissue infection. ___ ___ Doppler U/S No definite evidence of deep venous thrombosis in the bilateral lower extremity veins. Please note that the right peroneal veins were not visualized. ___ CXR No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Minimal streak of atelectasis at the left base. Brief Hospital Course: =============== BRIEF SUMMARY =============== ___ with T1DM c/b ESRD s/p renal/pancreas transplant in ___ c/b pancreas rejection, admitted from prison for right toe gangrene and osteomyelitis. He was evaluated by Vascular Surgery and Podiatry. He underwent angioplasty and limited amputation but continued to have poor wound healing and eventually required trans-metatarsal amputation of all five toes. He was initially treated with broad-spectrum antibiotics which were discontinued after definitive source control. He was discharged to pain free on dual antiplatelet therapy, high-dose statin, and optimized insulin regimen with close Podiatry and Vascular follow-up. ================ ACUTE ISSUES ================ # Sepsis # Right foot gangrene and osteomyelitis # Peripheral arterial disease Vascular Surgery, Podiatry, and ID were consulted. Patient underwent angioplasty followed by third toe amputation, excisional debridement, and eventually trans-metatarsal amputation (TMA) on ___. TMA deemed necessary as patient exhibited poor wound healing, likely due to ongoing ischemic disease. He was initially treated with vancomycin/pip-tazo, later narrowed to ceftriaxone/metronidazole and eventually discontinued 48 hours after definitive source control. He was started on a 1-month course of clopidogrel along with aspirin. Home atorvastatin was increased from 10 to 80 mg daily with no adverse effects. # Post-operative fevers Patient had post-operative fevers of unclear source despite thorough workup. These resolved and patient was afebrile for several days off antibiotics prior to discharge. # ___ s/p failed pancreas transplant: Diagnosed at age ___. Pancreas transplant reportedly failed after ~6 mos. ___ Diabetes Service was consulted. Patient was switched from NPH/regular to Lantus/Humalog regimen, which was titrated for improved control. He continued to have intermittent hyperglycemia which will require ongoing monitoring and close adjustment to optimize wound healing. # Deceased donor kidney/pancreas transplant ___, ___) Transplant Nephrology was consulted. Creatinine remained at baseline and urine output was robust. - Tacrolimus was increased to 3mg BID based on daily trough levels (goal ___ - MMF 500 mg BID was continued - Methylpred 4mg 3x/wk MWF, 2mg 4x/wk was continued - Vitamin D was continued - Patient is not on PJP prophylaxis ================ CHRONIC ISSUES ================ # Hypertension: Home amlodipine was continued with good control. # Dyslipidemia: Atorvastatin was increased from 10 to 80 mg daily per above. # GERD: Omeprazole 20mg daily was continued. ====================== TRANSITIONAL ISSUES ====================== # Post-Operative Care: - Please apply betadine dressing and change every 3 days. - Ensure follow up with Podiatry and Vascular Surgery (scheduled, see attached). # PAD: - Started on clopidogrel for 1-month course (last day ___. - Continue aspirin for life (at least 81mg; may increase back to 325mg) - Increased atorvastatin 10mg to 80mg given severity of PAD and high risk for MI/CVA. # DM1: - NPH/regular changed to Lantus/Humalog regimen for better glycemic control and wound healing. - Please monitor blood glucose QACHS and adjust as needed, goal glucose 130-180. # Contact: wife, ___, ___ # Code Status: Presumed full >30 minutes in patient care and coordination of discharge on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. NPH 22 Units Breakfast NPH 16 Units Dinner Regular 5 Units Breakfast Regular 5 Units Lunch Regular 5 Units Dinner Insulin SC Sliding Scale using REG Insulin 5. Methylprednisolone 4 mg PO 3X/WEEK (___) 6. Mycophenolate Mofetil 500 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Tacrolimus 2 mg PO QAM 9. Tacrolimus 1 mg PO QPM 10. Vitamin D ___ UNIT PO 1X/WEEK (___) 11. Methylprednisolone 2 mg PO 4X/WEEK (___) Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not take more than 4000 mg in one day 2. Clopidogrel 75 mg PO DAILY Duration: 1 Month 3. Dakins ___ Strength 1 Appl TP ASDIR 4. Glargine 33 Units Lunch Humalog 15 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Senna 8.6 mg PO BID:PRN constipation 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Tacrolimus 3 mg PO Q12H 9. amLODIPine 10 mg PO DAILY 10. Methylprednisolone 4 mg PO 3X/WEEK (___) 11. Methylprednisolone 2 mg PO 4X/WEEK (___) 12. Mycophenolate Mofetil 500 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Sepsis Left digit gangrene and osteomyelitis status post amputation Peripheral arterial disease status post angioplasty Type 1 diabetes mellitus SECONDARY DIAGNOSES History of kidney and pancreas transplant Chronic immunosuppressive therapy Hypertension Dyslipidemia 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: Mr. ___, It was a pleasure taking care of you in the hospital. WHY WAS I ADMITTED? You were admitted because your foot was infected. WHAT HAPPENED WHEN I WAS HERE? - You were seen by the foot and blood vessel surgeons. - You had multiple surgeries to try to save your third toe. - Unfortunately, there was not enough blood getting to your toes to help them heal so you needed an amputation. WHAT SHOULD I DO WHEN I LEAVE? - Keep taking all of your medications. - Follow up with your doctors. - Keep working with physical therapy to build up your strength and balance. We wish you all the best. Sincerely, Your ___ care team Followup Instructions: ___
[ "A419", "T86890", "I70261", "T86891", "E1052", "M869", "Z940", "Z794", "E1069", "I10", "K219", "E10319", "H548", "E785", "E669", "Z6827", "B9620", "Y830", "T8789", "Y835", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Necrotic toe, fevers Major Surgical or Invasive Procedure: [MASKED] necrotic [MASKED] toe amputation [MASKED] angioplasty [MASKED] right foot debridement [MASKED] TMA/TAL History of Present Illness: [MASKED] with type 1 DM c/b ESRD s/p renal/pancreas transplant in [MASKED] ([MASKED]) w/ failed pancreas transplant w/in [MASKED], presenting from prison due to worsening third right toe infection with gangrene and surrounding erythema. Per note from [MASKED] facility, patient with dry gangrene on right third toe wound. XRay at facility showed no gas or evidence of osteomyelitis. Per nursing report at his facility, they noticed increased erythema surrounding wound and now with drainage noted during dressing changes. Patient reports his symptoms began about one month ago. He reports that he repeatedly requested antibiotics and pain medications but was denied both until today. Past Medical History: Right foot wound Type I DM Kidney transplant/failed pancreas transplant [MASKED] ([MASKED]) Proliferative diabetic retinopathy, legally blind (R eye blind, L eye 200/20 vision) GERD w/o esophagitis HTN HLD Social History: [MASKED] Family History: Unaware of any renal disease or diabetes in the family Physical Exam: Admission Exam ================== VS: Temp 98.7 F PO 151/95 RR 98 RR 17 96% RA FSBG 265 General: Alert, oriented, no acute distress HEENT: No pallor. no icterus. Milky right eye, blind. Left eye sclera anicteric, no conjunctiva injection. CV: Regular rate and rhythm, normal S1 + S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present. No allograft tenderness. Ext: No edema. Right foot is bandaged. DP and [MASKED] on left foot faintly palpable, warm, no sensation, no lesion. Right foot warm, dopplerable pluses, moving toes, no sensation, dressed c/d/I. Neuro: No asterixis Discharge Exam ================== VS: T 98.5 PO BP 110/70 HR 97 SpO2 98 RA General: Alert, NAD. HEENT: Cloudy right eye, blind. No icterus or injection. MMM. CV: Regular pulse. Resp: Non-labored. Abdomen: Soft, NDNT. Ext: Warm, no edema. Right foot in multipodus boot. Dressing CDI. Surgical site is well coapted w/ sutures intact to R TMA site as well as TAL site. No local signs of dehiscence or infection. Pertinent Results: ADMISSION LABS: ==================== [MASKED] 09:30AM BLOOD WBC-9.5 RBC-4.26* Hgb-11.7* Hct-36.8* MCV-86 MCH-27.5 MCHC-31.8* RDW-13.0 RDWSD-40.4 Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-72.2* Lymphs-14.8* Monos-11.5 Eos-0.5* Baso-0.2 Im [MASKED] AbsNeut-6.86* AbsLymp-1.41 AbsMono-1.09* AbsEos-0.05 AbsBaso-0.02 [MASKED] 09:30AM BLOOD Plt [MASKED] [MASKED] 09:30AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 09:30AM BLOOD Glucose-386* UreaN-11 Creat-1.0 Na-136 K-4.1 Cl-92* HCO3-22 AnGap-22* [MASKED] 09:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 [MASKED] 12:30AM BLOOD CRP-146.6* [MASKED] 09:30AM BLOOD tacroFK-4.0* [MASKED] 12:49AM BLOOD Lactate-1.5 DISCHARGE LABS: ======================== [MASKED] 05:25AM BLOOD WBC-8.4 RBC-3.78* Hgb-10.1* Hct-31.8* MCV-84 MCH-26.7 MCHC-31.8* RDW-13.5 RDWSD-41.1 Plt [MASKED] [MASKED] 10:40AM BLOOD Glucose-286* UreaN-13 Creat-0.8 Na-135 K-4.2 Cl-95* HCO3-27 AnGap-13 MICRO: ===================== [MASKED] [MASKED] 10:45 am TISSUE [MASKED] METATARSAL HEAD. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] [MASKED] 9:03 am TISSUE Site: FOOT RIGHT FOOT TISSUE. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [MASKED]: ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [MASKED] [MASKED] BLOOD CULTURE - negative (final) [MASKED] BLOOD CULTURE - negative (final) [MASKED] BLOOD CULTURE - negative (final) [MASKED] BLOOD CULTURE - NGTD PATHOLOGY: ====================== [MASKED] Pathology Tissue: TOES, AMPUTATION, NON-TRAUMATIC 1. [MASKED] toe, right foot, amputation: [MASKED] toe with gangrene necrosis. 2. Margin, [MASKED] toe, right foot, amputation: Trabecular bone with no inflammation identifIed. [MASKED] Pathology Tissue: FOREIGN BODY, GROSS ONLY "Possible foreign body," right foot, excisional debridement: Partially necrotic fibroadipose tissue and blood vessels with extensive calcification along the internal elastic lamina; scant fragments of necrotic bone. Multiple levels examined. [MASKED] Pathology Tissue: TOES, AMPUTATION, NON-TRAUMATIC 1. Toes, right side, amputation: Gangrene 2. Metatarsal heads: One of five bones shows focal acute osteomyelitis (2D, multiple levels examined). 3. Third metatarsal head: Focal acute osteomyelitis. IMAGING & STUDIES: ====================== [MASKED] ARTERIAL U/S (REST ONLY) 1. Significant tibial arterial insufficiency to the lower extremities bilaterally, at rest. 2. Bilateral toe pressures < 30, likely contributing to for wound healing. [MASKED] ANGIOGRAM FINDINGS: 1. Normal caliber abdominal aorta without ectasia or stenosis. 2. Patent bilateral iliac artery systems. 3. Patent right common femoral and profunda femoris arteries. 4. Patent right superficial femoral artery. 5. Patent right popliteal artery. 6. Patent tibial trifurcation. The anterior tibial artery is patent proximally but occludes. The posterior tibial artery is patent to the ankle. The peroneal artery is patent proximally but has several areas of focal stenosis and then lateralizes to the dorsalis pedis at the ankle. 7. At the ankle, the posterior tibial arteries patent and runs off to the foot. The anterior tibial artery is occluded. Following intervention, the peroneal artery is patent to the ankle and collateralizes to the lateral tarsal vessels in the foot. [MASKED] XR FOOT AP,LAT & OBL RIGHT Status post transmetatarsal amputation of all 5 rays, right foot. Subcutaneous gas in the soft tissues posterior to the distal tibia. This may be tracking from the surgical site but correlate for soft tissue defects or signs of soft tissue infection. [MASKED] [MASKED] Doppler U/S No definite evidence of deep venous thrombosis in the bilateral lower extremity veins. Please note that the right peroneal veins were not visualized. [MASKED] CXR No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Minimal streak of atelectasis at the left base. Brief Hospital Course: =============== BRIEF SUMMARY =============== [MASKED] with T1DM c/b ESRD s/p renal/pancreas transplant in [MASKED] c/b pancreas rejection, admitted from prison for right toe gangrene and osteomyelitis. He was evaluated by Vascular Surgery and Podiatry. He underwent angioplasty and limited amputation but continued to have poor wound healing and eventually required trans-metatarsal amputation of all five toes. He was initially treated with broad-spectrum antibiotics which were discontinued after definitive source control. He was discharged to pain free on dual antiplatelet therapy, high-dose statin, and optimized insulin regimen with close Podiatry and Vascular follow-up. ================ ACUTE ISSUES ================ # Sepsis # Right foot gangrene and osteomyelitis # Peripheral arterial disease Vascular Surgery, Podiatry, and ID were consulted. Patient underwent angioplasty followed by third toe amputation, excisional debridement, and eventually trans-metatarsal amputation (TMA) on [MASKED]. TMA deemed necessary as patient exhibited poor wound healing, likely due to ongoing ischemic disease. He was initially treated with vancomycin/pip-tazo, later narrowed to ceftriaxone/metronidazole and eventually discontinued 48 hours after definitive source control. He was started on a 1-month course of clopidogrel along with aspirin. Home atorvastatin was increased from 10 to 80 mg daily with no adverse effects. # Post-operative fevers Patient had post-operative fevers of unclear source despite thorough workup. These resolved and patient was afebrile for several days off antibiotics prior to discharge. # [MASKED] s/p failed pancreas transplant: Diagnosed at age [MASKED]. Pancreas transplant reportedly failed after ~6 mos. [MASKED] Diabetes Service was consulted. Patient was switched from NPH/regular to Lantus/Humalog regimen, which was titrated for improved control. He continued to have intermittent hyperglycemia which will require ongoing monitoring and close adjustment to optimize wound healing. # Deceased donor kidney/pancreas transplant [MASKED], [MASKED]) Transplant Nephrology was consulted. Creatinine remained at baseline and urine output was robust. - Tacrolimus was increased to 3mg BID based on daily trough levels (goal [MASKED] - MMF 500 mg BID was continued - Methylpred 4mg 3x/wk MWF, 2mg 4x/wk was continued - Vitamin D was continued - Patient is not on PJP prophylaxis ================ CHRONIC ISSUES ================ # Hypertension: Home amlodipine was continued with good control. # Dyslipidemia: Atorvastatin was increased from 10 to 80 mg daily per above. # GERD: Omeprazole 20mg daily was continued. ====================== TRANSITIONAL ISSUES ====================== # Post-Operative Care: - Please apply betadine dressing and change every 3 days. - Ensure follow up with Podiatry and Vascular Surgery (scheduled, see attached). # PAD: - Started on clopidogrel for 1-month course (last day [MASKED]. - Continue aspirin for life (at least 81mg; may increase back to 325mg) - Increased atorvastatin 10mg to 80mg given severity of PAD and high risk for MI/CVA. # DM1: - NPH/regular changed to Lantus/Humalog regimen for better glycemic control and wound healing. - Please monitor blood glucose QACHS and adjust as needed, goal glucose 130-180. # Contact: wife, [MASKED], [MASKED] # Code Status: Presumed full >30 minutes in patient care and coordination of discharge on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. NPH 22 Units Breakfast NPH 16 Units Dinner Regular 5 Units Breakfast Regular 5 Units Lunch Regular 5 Units Dinner Insulin SC Sliding Scale using REG Insulin 5. Methylprednisolone 4 mg PO 3X/WEEK ([MASKED]) 6. Mycophenolate Mofetil 500 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Tacrolimus 2 mg PO QAM 9. Tacrolimus 1 mg PO QPM 10. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) 11. Methylprednisolone 2 mg PO 4X/WEEK ([MASKED]) Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not take more than 4000 mg in one day 2. Clopidogrel 75 mg PO DAILY Duration: 1 Month 3. Dakins [MASKED] Strength 1 Appl TP ASDIR 4. Glargine 33 Units Lunch Humalog 15 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Senna 8.6 mg PO BID:PRN constipation 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Tacrolimus 3 mg PO Q12H 9. amLODIPine 10 mg PO DAILY 10. Methylprednisolone 4 mg PO 3X/WEEK ([MASKED]) 11. Methylprednisolone 2 mg PO 4X/WEEK ([MASKED]) 12. Mycophenolate Mofetil 500 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES Sepsis Left digit gangrene and osteomyelitis status post amputation Peripheral arterial disease status post angioplasty Type 1 diabetes mellitus SECONDARY DIAGNOSES History of kidney and pancreas transplant Chronic immunosuppressive therapy Hypertension Dyslipidemia 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: Mr. [MASKED], It was a pleasure taking care of you in the hospital. WHY WAS I ADMITTED? You were admitted because your foot was infected. WHAT HAPPENED WHEN I WAS HERE? - You were seen by the foot and blood vessel surgeons. - You had multiple surgeries to try to save your third toe. - Unfortunately, there was not enough blood getting to your toes to help them heal so you needed an amputation. WHAT SHOULD I DO WHEN I LEAVE? - Keep taking all of your medications. - Follow up with your doctors. - Keep working with physical therapy to build up your strength and balance. We wish you all the best. Sincerely, Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "Z794", "I10", "K219", "E785", "E669", "Y92230" ]
[ "A419: Sepsis, unspecified organism", "T86890: Other transplanted tissue rejection", "I70261: Atherosclerosis of native arteries of extremities with gangrene, right leg", "T86891: Other transplanted tissue failure", "E1052: Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "M869: Osteomyelitis, unspecified", "Z940: Kidney transplant status", "Z794: Long term (current) use of insulin", "E1069: Type 1 diabetes mellitus with other specified complication", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "H548: Legal blindness, as defined in USA", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "T8789: Other complications of amputation stump", "Y835: Amputation of limb(s) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,063,848
21,345,067
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Attending: ___. Chief Complaint: abdominal pain, nausea, non-bilious emesis, abdominal distension Major Surgical or Invasive Procedure: ___: Exploratory laparotomy with enterotomies and small bowel resection with Dr. ___ ___ of Present Illness: ___ who presented with abdominal pain, nausea, distension, and multiple bouts of bilious, non bloody emesis. Her pain started the evening of ___, and was described as sharp, continuous, along mid abdomen. She had taken minimal PO and her pain worsened the day prior to presenting to the ER, which prompted her to seek treatment. She had not passed flatus since ___ and her last bowel movement was 3 days prior to presentation. She has had previous bowel obstructions that caused similar symptoms. She has a hx of an open cholecystectomy, appendectomy, and hysterectomy in the distant past as well as a LOA and SBR for an SBO in the ___. Her last SBO was in ___ at the time of her last surgery. Past Medical History: PMH: ___ disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in ___ (last SBO), right shoulder dislocation s/ p repair ___ Social History: ___ Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISSION PHYSICAL EXAM: Phx: 98.5 78 142/75 18 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, distended, TTP along mid abdomen and right side, no rebound, + guarding, well healed lower abdominal, RLQ, and subcostal incisions Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: VS: 97.4 PO 94 / 48 R Sitting 95 18 96 RA General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi. Decreased breath sounds at the bases. CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, slightly tender in right quadrants, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Surgical scar midline with wound vac in place GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ ___ edema bilaterally Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ============== ___ 11:45PM BLOOD WBC-12.2* RBC-4.89 Hgb-14.3 Hct-44.2 MCV-90 MCH-29.2 MCHC-32.4 RDW-15.2 RDWSD-50.3* Plt ___ ___ 11:45PM BLOOD Neuts-81.3* Lymphs-10.5* Monos-7.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.88* AbsLymp-1.28 AbsMono-0.92* AbsEos-0.03* AbsBaso-0.03 ___ 11:45PM BLOOD Plt ___ ___ 07:30AM BLOOD ___ PTT-27.7 ___ ___ 01:15PM BLOOD FacVIII-208* ___ 01:15PM BLOOD VWF AG-190* VWF ___ ___ 11:45PM BLOOD Glucose-130* UreaN-28* Creat-0.9 Na-142 K-4.1 Cl-99 HCO3-26 AnGap-21* ================ RADIOLOGY: ___ CT A/P: 1. High grade small bowel obstruction likely caused by adhesions -with the transition point at the level of the umbilicus within the right anterior abdominal wall with upstream dilation of small bowel loops which are fluid filled, with complete collapse of the distal small bowel loops . Surgical consultation is recommended. 2. No bowel perforations. ___ Portable abdomen: 1. Nonspecific bowel gas pattern without evidence of obstruction. 2. NG tube is visualized with the tip terminating at the gastric antrum. 3. Second catheter projecting over the superior mediastinum for which clinical correlation is recommended, as above. ___ CXR: Mild pulmonary edema and bibasilar atelectasis. ___ CT A/P: 1. Focal small bowel ileus involving loops of small bowel leading up to the new surgical anastamosis. No bowel obstruction as suggested by distal passage of orally ingested contrast beyond the anastomosis. 2. No extraluminal contrast seen to suggest anastomotic leak. 3. New bibasilar opacities and small bilateral pleural effusions. This likely represents atelectasis, aspiration pneumonitis is also a consideration. 4. Nonobstructing 5 mm left lower pole nephrolithiasis. ___ CXR: 1. Nasogastric tube terminates in the distal stomach. 2. Interval improvement of pulmonary edema and left basilar atelectasis. ___ CXR PICC: after advancement IMPRESSION: Right PICC line tip in mid SVC. ___: ECHO Suboptimal image quality - poor apical views. Ascites. Conclusions The left atrium is normal in size. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Ascites is present. ___: CXR IMPRESSION: The left-sided PICC line has the distal tip in the distal SVC. Heart size is prominent but unchanged. There is again seen a left retrocardiac opacity and atelectasis at the lung bases. There is coarsening of the bronchovascular markings without overt pulmonary edema. There are no pneumothoraces. ___: LUNG VQ scan: IMPRESSION: 1. Low likelihood of acute pulmonary embolism. Mild irregularity on perfusion images and moderate to severe defects on ventilation defects likely representing airways disease. 2. Right lung is foreshortened compared to the left lung which is not accounted for on chest radiograph ___. Chest radiograph is recommended to rule out a pleural effusion. ============================= MICROBIOLOGY: ___ 9:53 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 09:53AM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM Pathology:======================================== ___: small bowel resection - segment f small bowel with areas of ischemic necrosis, edema, acute inflammation, perforation, and extensive serosal adhesions - one margin (blue ink) with serositis - three lymph nodes, no malignancy identified DISCHARGE LABS: =============== ___ 04:03AM BLOOD WBC-9.2 RBC-2.91* Hgb-8.3* Hct-26.3* MCV-90 MCH-28.5 MCHC-31.6* RDW-15.8* RDWSD-52.3* Plt ___ ___ 04:03AM BLOOD Plt ___ ___ 04:03AM BLOOD Glucose-98 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-102 HCO3-27 AnGap-14 ___ 04:03AM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.7 Mg-2.2 Brief Hospital Course: Ms. ___ is a ___ female with a history of ___ ___ disease who was admitted to the hospital with a small bowel obstruction requiring urgent open laparotomy and found to have mild pulmonary hypertension. #SBO s/p Open Laparotomy. Ms. ___ was admitted to ___ ___ after evaluation in the Emergency Department where she was found to have a small bowel obstruction on CT in the setting of previous abdominal surgeries and prior SBO. She was admitted to the Acute Care Surgery service overnight ___ for conservative management of her high grade bowel obstruction with low threshold for operative intervention. A nasogastric tube was placed for decompression and she had bowel rest with IV hydration and serial abdominal exams. In the evening of the same day, she was taken to the operating room for exploration with an exploratory laparotomy and lysis of adhesions, small bowel resection after failure of conservative management. Findings include 2 areas of dense matted adhesions of knotted small bowel loops, more proximally in the mid ileum and about one foot distally in the LLQ bowel was adhered to the rectus muscle. There was chronic thickening of the bowel wall between these sections with matting and this section was resected and a primary anastomosis was completed. #Acute Hypoxic Respiratory Failure: Unclear etiology but could be multifactorial from a component of pulmonary HTN and volume overload. Patient was diuresed with 10 mg IV Lasix BID with resolution of hypoxia. #SVT #Pulmonary Hypertension: She was transferred to the SICU with hypotension and SVT. She received 5mg metoprolol IV for SVT, an NGT was placed, and she had a CT A/P with PO contrast. This imaging found focal small bowel ileus with no obstruction as oral contrast passed the anastomosis, with no evidence of extravasation to support a leak. However, she was seen to have bibasilar opacities and small bilateral pleural effusions and an incidental left lower pole nephrolithiasis. On ___, she had a transthoracic echocardiogram for SVT with findings that included demonstrated hyperdynamic left ventricle (EF 75%), hypertrophied right ventricle with abnormal septal motion consistent with right volume overload, as well as severe pulmonary artery hypertension and significant pulmonic regurgitation, moderate tricuspid regurgitation, with thickened valves and ascites. She was diuresed with IV 10 Lasix BID. Because of frequent episodes of SVT, she was started on metoprolol tartrate 12.5 mg po BID that was then switched to metoprolol succinate 25 mg. Right heart catherization showed mild pulmonary hypertension with no immediate need for inpatient treatment and follow up in clinic. #CAUTI: Urine culture shows pansensitive E. Coli. She received 2 days of Bactrim before switching to macrobid in the setting of diarrhea to complete a 7-day course. #Thrombocytopenia: Patient developed thrombocytopenia. Per hematology, this could be a side effect from Bactrim and her peripheral smear was negative for schistocytes or platelet clumping. She had a negative PF4. TRANSITIONAL ISSUES =================== -SVT: Patient was started on metoprolol succinate 25 mg daily. Patient could have had SVT because of stress of surgery. Please re-assess need. -Patient was evaluated for home O2 and met criteria due to desats to 88% with ambulation in the setting of pulmonary hypertension. -Pulmonary Hypertension: Patient will need to be followed up in pulmonary hypertension clinic in ___ months for possible treatment. # CONTACT: Name of health care proxy: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide 2 mg 2 mg by mouth four times a day Disp #*20 Capsule Refills:*0 2. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Acetaminophen ___ mg PO PRN Pain - Mild 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5.___, commode Please provide walker and commode. Diagnosis: I27.0, ___ Prognosis: Good, Length: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Small bowel obstruction pulmonary hypertension impaired wound healing UTI nonobstructing left lower pole nephrolithiasis 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 Acute Care Surgery Team at ___ with abdominal pain and found to have an obstruction in your intestine. You were taken to the operating room for an exploratory laparotomy, lysis of adhesions, and small bowel resection to take out a piece of your small intestine that was stuck together and causing a blockage. After this, you had care in the ICU for rapid heart rate and low blood pressure. There, you had an echocardiogram to look at your heart, which found evidence of pulmonary hypertension (high blood pressure in an artery from the right side of your heart to your lungs). You also had extra fluid, which was slowly relieved by giving you furosemide which caused you to urinate off extra fluid. The pulmonary service was involved in your care for this new diagnosis of pulmonary hypertension and they recommend a right heart catheterization. You had mild pulmonary hypertension and you should follow up with the lung doctors ___ ___ months for possible treatment. Your abdominal incision had minor redness, and some of your staples were removed and a new dressing was placed. After a few days, a wound vacuum dressing was put on to help heal your wound faster and remove the fluid there. You were also found to have a urinary tract infection, which was treated with antibiotics. 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 and should continue to walk several times a day. 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 You may shower with covering your vacuum dressing*******. You may wash over your staples, allowing the warm water to run over the incision. Pat dry, do not rub. Do not bathe, soak, or swim until cleared by your surgeon.** MAY DIFFER DEPENDING ON VAC ETC o Your incisions may be slightly red around the staples. 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. 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. We wish you the best, Your care team at ___ Followup Instructions: ___
[ "K565", "J9601", "D680", "I272", "D6959", "K521", "I471", "N390", "D62", "K567", "B9620", "T370X5A", "Y92239", "I509", "N200", "E876", "E8342", "F419", "R252" ]
Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Chief Complaint: abdominal pain, nausea, non-bilious emesis, abdominal distension Major Surgical or Invasive Procedure: [MASKED]: Exploratory laparotomy with enterotomies and small bowel resection with Dr. [MASKED] [MASKED] of Present Illness: [MASKED] who presented with abdominal pain, nausea, distension, and multiple bouts of bilious, non bloody emesis. Her pain started the evening of [MASKED], and was described as sharp, continuous, along mid abdomen. She had taken minimal PO and her pain worsened the day prior to presenting to the ER, which prompted her to seek treatment. She had not passed flatus since [MASKED] and her last bowel movement was 3 days prior to presentation. She has had previous bowel obstructions that caused similar symptoms. She has a hx of an open cholecystectomy, appendectomy, and hysterectomy in the distant past as well as a LOA and SBR for an SBO in the [MASKED]. Her last SBO was in [MASKED] at the time of her last surgery. Past Medical History: PMH: [MASKED] disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in [MASKED] (last SBO), right shoulder dislocation s/ p repair [MASKED] Social History: [MASKED] Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISSION PHYSICAL EXAM: Phx: 98.5 78 142/75 18 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, distended, TTP along mid abdomen and right side, no rebound, + guarding, well healed lower abdominal, RLQ, and subcostal incisions Ext: No [MASKED] edema, [MASKED] warm and well perfused DISCHARGE PHYSICAL EXAM: VS: 97.4 PO 94 / 48 R Sitting 95 18 96 RA General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi. Decreased breath sounds at the bases. CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, slightly tender in right quadrants, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Surgical scar midline with wound vac in place GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ [MASKED] edema bilaterally Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ============== [MASKED] 11:45PM BLOOD WBC-12.2* RBC-4.89 Hgb-14.3 Hct-44.2 MCV-90 MCH-29.2 MCHC-32.4 RDW-15.2 RDWSD-50.3* Plt [MASKED] [MASKED] 11:45PM BLOOD Neuts-81.3* Lymphs-10.5* Monos-7.6 Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-9.88* AbsLymp-1.28 AbsMono-0.92* AbsEos-0.03* AbsBaso-0.03 [MASKED] 11:45PM BLOOD Plt [MASKED] [MASKED] 07:30AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 01:15PM BLOOD FacVIII-208* [MASKED] 01:15PM BLOOD VWF AG-190* VWF [MASKED] [MASKED] 11:45PM BLOOD Glucose-130* UreaN-28* Creat-0.9 Na-142 K-4.1 Cl-99 HCO3-26 AnGap-21* ================ RADIOLOGY: [MASKED] CT A/P: 1. High grade small bowel obstruction likely caused by adhesions -with the transition point at the level of the umbilicus within the right anterior abdominal wall with upstream dilation of small bowel loops which are fluid filled, with complete collapse of the distal small bowel loops . Surgical consultation is recommended. 2. No bowel perforations. [MASKED] Portable abdomen: 1. Nonspecific bowel gas pattern without evidence of obstruction. 2. NG tube is visualized with the tip terminating at the gastric antrum. 3. Second catheter projecting over the superior mediastinum for which clinical correlation is recommended, as above. [MASKED] CXR: Mild pulmonary edema and bibasilar atelectasis. [MASKED] CT A/P: 1. Focal small bowel ileus involving loops of small bowel leading up to the new surgical anastamosis. No bowel obstruction as suggested by distal passage of orally ingested contrast beyond the anastomosis. 2. No extraluminal contrast seen to suggest anastomotic leak. 3. New bibasilar opacities and small bilateral pleural effusions. This likely represents atelectasis, aspiration pneumonitis is also a consideration. 4. Nonobstructing 5 mm left lower pole nephrolithiasis. [MASKED] CXR: 1. Nasogastric tube terminates in the distal stomach. 2. Interval improvement of pulmonary edema and left basilar atelectasis. [MASKED] CXR PICC: after advancement IMPRESSION: Right PICC line tip in mid SVC. [MASKED]: ECHO Suboptimal image quality - poor apical views. Ascites. Conclusions The left atrium is normal in size. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Ascites is present. [MASKED]: CXR IMPRESSION: The left-sided PICC line has the distal tip in the distal SVC. Heart size is prominent but unchanged. There is again seen a left retrocardiac opacity and atelectasis at the lung bases. There is coarsening of the bronchovascular markings without overt pulmonary edema. There are no pneumothoraces. [MASKED]: LUNG VQ scan: IMPRESSION: 1. Low likelihood of acute pulmonary embolism. Mild irregularity on perfusion images and moderate to severe defects on ventilation defects likely representing airways disease. 2. Right lung is foreshortened compared to the left lung which is not accounted for on chest radiograph [MASKED]. Chest radiograph is recommended to rule out a pleural effusion. ============================= MICROBIOLOGY: [MASKED] 9:53 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 09:53AM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM Pathology:======================================== [MASKED]: small bowel resection - segment f small bowel with areas of ischemic necrosis, edema, acute inflammation, perforation, and extensive serosal adhesions - one margin (blue ink) with serositis - three lymph nodes, no malignancy identified DISCHARGE LABS: =============== [MASKED] 04:03AM BLOOD WBC-9.2 RBC-2.91* Hgb-8.3* Hct-26.3* MCV-90 MCH-28.5 MCHC-31.6* RDW-15.8* RDWSD-52.3* Plt [MASKED] [MASKED] 04:03AM BLOOD Plt [MASKED] [MASKED] 04:03AM BLOOD Glucose-98 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-102 HCO3-27 AnGap-14 [MASKED] 04:03AM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.7 Mg-2.2 Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with a history of [MASKED] [MASKED] disease who was admitted to the hospital with a small bowel obstruction requiring urgent open laparotomy and found to have mild pulmonary hypertension. #SBO s/p Open Laparotomy. Ms. [MASKED] was admitted to [MASKED] [MASKED] after evaluation in the Emergency Department where she was found to have a small bowel obstruction on CT in the setting of previous abdominal surgeries and prior SBO. She was admitted to the Acute Care Surgery service overnight [MASKED] for conservative management of her high grade bowel obstruction with low threshold for operative intervention. A nasogastric tube was placed for decompression and she had bowel rest with IV hydration and serial abdominal exams. In the evening of the same day, she was taken to the operating room for exploration with an exploratory laparotomy and lysis of adhesions, small bowel resection after failure of conservative management. Findings include 2 areas of dense matted adhesions of knotted small bowel loops, more proximally in the mid ileum and about one foot distally in the LLQ bowel was adhered to the rectus muscle. There was chronic thickening of the bowel wall between these sections with matting and this section was resected and a primary anastomosis was completed. #Acute Hypoxic Respiratory Failure: Unclear etiology but could be multifactorial from a component of pulmonary HTN and volume overload. Patient was diuresed with 10 mg IV Lasix BID with resolution of hypoxia. #SVT #Pulmonary Hypertension: She was transferred to the SICU with hypotension and SVT. She received 5mg metoprolol IV for SVT, an NGT was placed, and she had a CT A/P with PO contrast. This imaging found focal small bowel ileus with no obstruction as oral contrast passed the anastomosis, with no evidence of extravasation to support a leak. However, she was seen to have bibasilar opacities and small bilateral pleural effusions and an incidental left lower pole nephrolithiasis. On [MASKED], she had a transthoracic echocardiogram for SVT with findings that included demonstrated hyperdynamic left ventricle (EF 75%), hypertrophied right ventricle with abnormal septal motion consistent with right volume overload, as well as severe pulmonary artery hypertension and significant pulmonic regurgitation, moderate tricuspid regurgitation, with thickened valves and ascites. She was diuresed with IV 10 Lasix BID. Because of frequent episodes of SVT, she was started on metoprolol tartrate 12.5 mg po BID that was then switched to metoprolol succinate 25 mg. Right heart catherization showed mild pulmonary hypertension with no immediate need for inpatient treatment and follow up in clinic. #CAUTI: Urine culture shows pansensitive E. Coli. She received 2 days of Bactrim before switching to macrobid in the setting of diarrhea to complete a 7-day course. #Thrombocytopenia: Patient developed thrombocytopenia. Per hematology, this could be a side effect from Bactrim and her peripheral smear was negative for schistocytes or platelet clumping. She had a negative PF4. TRANSITIONAL ISSUES =================== -SVT: Patient was started on metoprolol succinate 25 mg daily. Patient could have had SVT because of stress of surgery. Please re-assess need. -Patient was evaluated for home O2 and met criteria due to desats to 88% with ambulation in the setting of pulmonary hypertension. -Pulmonary Hypertension: Patient will need to be followed up in pulmonary hypertension clinic in [MASKED] months for possible treatment. # CONTACT: Name of health care proxy: [MASKED] Relationship: Husband Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen [MASKED] mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide 2 mg 2 mg by mouth four times a day Disp #*20 Capsule Refills:*0 2. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Acetaminophen [MASKED] mg PO PRN Pain - Mild 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5.[MASKED], commode Please provide walker and commode. Diagnosis: I27.0, [MASKED] Prognosis: Good, Length: 13 months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Small bowel obstruction pulmonary hypertension impaired wound healing UTI nonobstructing left lower pole nephrolithiasis 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 Acute Care Surgery Team at [MASKED] with abdominal pain and found to have an obstruction in your intestine. You were taken to the operating room for an exploratory laparotomy, lysis of adhesions, and small bowel resection to take out a piece of your small intestine that was stuck together and causing a blockage. After this, you had care in the ICU for rapid heart rate and low blood pressure. There, you had an echocardiogram to look at your heart, which found evidence of pulmonary hypertension (high blood pressure in an artery from the right side of your heart to your lungs). You also had extra fluid, which was slowly relieved by giving you furosemide which caused you to urinate off extra fluid. The pulmonary service was involved in your care for this new diagnosis of pulmonary hypertension and they recommend a right heart catheterization. You had mild pulmonary hypertension and you should follow up with the lung doctors [MASKED] [MASKED] months for possible treatment. Your abdominal incision had minor redness, and some of your staples were removed and a new dressing was placed. After a few days, a wound vacuum dressing was put on to help heal your wound faster and remove the fluid there. You were also found to have a urinary tract infection, which was treated with antibiotics. 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 and should continue to walk several times a day. 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 You may shower with covering your vacuum dressing*******. You may wash over your staples, allowing the warm water to run over the incision. Pat dry, do not rub. Do not bathe, soak, or swim until cleared by your surgeon.** MAY DIFFER DEPENDING ON VAC ETC o Your incisions may be slightly red around the staples. 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. 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. We wish you the best, Your care team at [MASKED] Followup Instructions: [MASKED]
[]
[ "J9601", "N390", "D62", "F419" ]
[ "K565: Intestinal adhesions [bands] with obstruction (postinfection)", "J9601: Acute respiratory failure with hypoxia", "D680: Von Willebrand's disease", "I272: Other secondary pulmonary hypertension", "D6959: Other secondary thrombocytopenia", "K521: Toxic gastroenteritis and colitis", "I471: Supraventricular tachycardia", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "K567: Ileus, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T370X5A: Adverse effect of sulfonamides, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I509: Heart failure, unspecified", "N200: Calculus of kidney", "E876: Hypokalemia", "E8342: Hypomagnesemia", "F419: Anxiety disorder, unspecified", "R252: Cramp and spasm" ]
10,063,848
24,092,966
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex / Bactrim Attending: ___. Chief Complaint: Enterocutaneous fistula Major Surgical or Invasive Procedure: Placement of wound vac ___ Successful CT-guided placement of an ___ pigtail catheter into an abdominal collection - ___ Successful replacement of CT-guided placement of an ___ pigtail catheter into an abdominal collection - ___ History of Present Illness: ___ is a ___ y/o F hx of ___ disease, syringomyelia, and SBO in ___, s/p exploratory laparotomy, lysis of adhesions and small bowel resection (90 cm) with primary anastomosis (no ostomy) on ___ by Dr. ___. As an outpatient the patient developed issues with stool leakage around her ostomy site, and on ___ she was admitted to ___ to surgical service where she had CT scan. This scan showed 2.5cm focus of (organizing fluid) demonstrated deep to dehiscence of her surgical site. In addition there was gas from her anastomosis suggestive of bowel perforation or anastomotic leak, and it was suggested at that time to obtain a CT abdomen and pelvis with oral contrast. During that admission, she was fitted with an ostomy appliance overlying her wound, but continues to leak around her ostomy bag. For this reason she came to the ___ ED. In the ED, she was evaluated by surgical service who felt she was stable for outpatient management, and they temporized the leaking of the ostomy. In the ED, initial vitals were: 98.0 ___ 18 100% RA - Exam notable for: Tachycardic Stool leaking around inferior and lower right edges of appliance. Area of purulence on left - Labs notable for: ___ 00:22 Lactate:1.5 ___ 00:05 ___: 13.5 PTT: 27.8 INR: 1.2 Urinalysis: contaminated w/epis 138 101 13 ============<105 4.0 23 0.6 10.0<9.5/30.5>313 ___ - Imaging was notable for: ___: CXR Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded, particularly in the appropriate clinical setting. - ACS was consulted: noted that ostomy looked good, no need for inpatient admission - Patient was given: 1L NS - Vitals prior to transfer: 88 103/40 16 97% RA Upon arrival to the floor, patient reports she has had a cough since her surgery, denies fever, chills, abdominal pain, chest pain, nausea, vomiting, other symptoms. Past Medical History: PMH: ___ disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in ___ (last SBO), right shoulder dislocation s/ p repair ___ Social History: ___ Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISSION EXAM Vital Signs: 98.2 112 / 70 95 18 94 RA General: Alert, oriented, fatigued appearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. CV: Mild tachycardia. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, diminished bilateral bases. Abdomen: Distended, non-tender on deep palpation, +bowel sounds. Patient w/surgical site covered in newly placed vac covered by ostomy bag. This was placed a few hours prior to exam and stool is leaking around the vac. GU: No foley Ext: Warm, well perfused Neuro: gait deferred Discharge Physical Exam: Vitals - Pertinent Results: ADMISSION LABS ___ 08:20PM BLOOD WBC-10.0 RBC-3.47* Hgb-9.5* Hct-30.5* MCV-88 MCH-27.4 MCHC-31.1* RDW-15.6* RDWSD-50.3* Plt ___ ___ 08:20PM BLOOD Neuts-60.7 ___ Monos-12.9 Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.09 AbsLymp-2.59 AbsMono-1.30* AbsEos-0.01* AbsBaso-0.02 ___ 08:20PM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-23 AnGap-18 ___ 08:20PM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 ___ 12:22AM BLOOD Lactate-1.5 RADIOLOGY ___ Imaging CHEST (PA & LAT) FINDINGS: The lungs appear hypoinflated. Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded. Linear opacities in the left lung likely represent atelectasis. There is no pulmonary edema or pneumothorax. The cardiomediastinal silhouette and hilar contours are exaggerated by low lung volumes but appear unchanged. IMPRESSION: Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded, particularly in the appropriate clinical setting. ___BD & PELVIS WITH CO IMPRESSION: 1. There is large irregular peripherally enhancing air-fluid collection right lower quadrant, below the cecum, abutting anterior abdominal wall, consistent with abscess. 2. Findings concerning for leak at the level of the umbilicus, with high-density material likely representing enteric contrast that has extravasated, and enterocutaneous fistula covered by a wound VAC. 3. Hepatic steatosis. CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 4:47 ___ IMPRESSION: 1. Marked interval decrease in the size of the previously seen large abscess in the right lower quadrant, now a shallow collection of gas and fluid measuring up to 1.6 cm in greatest thickness. This collection is too small for a drain to be placed. The previously placed pigtail catheter is retracted and located within the anterior abdominal wall. 2. The patient's known anterior abdominal wall enterocutaneous fistula is incompletely evaluated in the absence of oral contrast but appears overall similar compared to prior studies. There is no evidence of obstruction. No new fluid collections are seen. Brief Hospital Course: ___ y/o F hx of ___ disease, syringomyelia, and SBO in ___, s/p exploratory laparotomy, lysis of adhesions and small bowel resection (90 cm) with primary anastomosis (no ostomy) on ___ by Dr. ___ presenting w/ongoing enterocutaneous fistula and leakage around ostomy bag along a new enterocutanous fistula with hypotension and tachycardia. Hypotension was thought to be from increased ostomy output and improved with IV fluid resuscitation. Surgery saw the patient and noted that she had a new, enterocutaneous fistula. A wound vac was placed. The thought was that this would improve the dynamics of the drainage from the current enterocutaneous fistula. A CT scan was performed which was reviewed with the surgical team. Upon review, a fluid collection was demonstrated. At this time the patient was transferred to the surgical service for ___ guided drainage. Of note, there was initial concern for pneumonia upon presentation and the patient received a dose of doxycycline given her allergies. This was discontinued as upon further review, it was not determined that the patient had a pneumonia. On Hospital Day 2, the patient went to Interventional Radiology for placement for a drain for the RLQ abdominal abscess. She was started on broad-spectrum IV antibiotics for the fluid collection as well as positive blood culture, although this was likely a contaminant as further blood cultures were negative. She was seen by wound ___ nursing staff who placed a pouch appliance for the entero-cutaneous fistula. The enterocutaneous fistula continued to put out ~500cc/day and was put to gravity. The pouch was resealed and replaced several times during her hospital course. The patient's IV antibiotics were narrowed to IV ceftazidime for cultures growing pansensitive E coli. The patient refused to take any other oral or IV antibiotics. She worked with Physical Therapy during her hospital stay which cleared her for home after a few more sessions, which were done. On Hospital Day 7, the patient's ___ drain was noted to have slipped out several inches, and so a CT abdomen/pelvis w/ PO/IV contrast was obtained which demonstrated the drain was located in the subcutaneous tissue and the RLQ abdominal fluid collection still present but slightly smaller in size. Interventional Radiology then replaced the drain. The patient was hospitalized for several more days to ensure the ostomy appliance was not leaking with movement. At this point, the patient had completed her 7-day course of antibiotics and was ready for discharge home with ___ for wound care and weekly clinic visit with the wound care clinic. She was ready for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Cyclobenzaprine 5 mg PO TID:PRN spasm 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 4. LORazepam 1 mg PO DAILY:PRN anxiety 5. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ENTEROCUTANEOUS FISTULA Abdominal fluid collection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital because you were having leaking from your chronic abdominal wound. You were seen by our surgical team who placed a wound vac to help alleviate the pressure on this wound. We repeated a CAT scan of your abdomen, which demonstrated an abdominal abscess. This was drained by Interventional Radiology and you were started on IV antibiotics. You were transferred to the Surgery Service for further care. The wound care/ostomy nurses have changed your ostomy appliance several times during your hospitalization to best exclude the enterocutaneous fistula and incorporate it as part of your wound care. You currently have ___ pouch. You were continued on IV antibiotics which were narrowed based on your drain culture results. You have now completed your course of antibiotics. Your drain slipped out a few inches and a repeat CT scan was obtained to assist Interventional Radiology in replacing your drain. Your drain was replaced successfully and your pouch has been holding for 48 hours since its last replacement. You are now ready for discharge home with nursing care for your ___ drain as well as ostomy pouch. You no longer require further antibiotics. Your discharge medications and follow up appointments are detailed below. Please follow the below instructions for a safe and speedy recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. We wish you the best! Your ___ team Followup Instructions: ___
[ "K632", "Y836", "K651", "G950", "I959", "D680", "I272", "K9403", "Y833", "Y929", "B9620" ]
Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex / Bactrim Chief Complaint: Enterocutaneous fistula Major Surgical or Invasive Procedure: Placement of wound vac [MASKED] Successful CT-guided placement of an [MASKED] pigtail catheter into an abdominal collection - [MASKED] Successful replacement of CT-guided placement of an [MASKED] pigtail catheter into an abdominal collection - [MASKED] History of Present Illness: [MASKED] is a [MASKED] y/o F hx of [MASKED] disease, syringomyelia, and SBO in [MASKED], s/p exploratory laparotomy, lysis of adhesions and small bowel resection (90 cm) with primary anastomosis (no ostomy) on [MASKED] by Dr. [MASKED]. As an outpatient the patient developed issues with stool leakage around her ostomy site, and on [MASKED] she was admitted to [MASKED] to surgical service where she had CT scan. This scan showed 2.5cm focus of (organizing fluid) demonstrated deep to dehiscence of her surgical site. In addition there was gas from her anastomosis suggestive of bowel perforation or anastomotic leak, and it was suggested at that time to obtain a CT abdomen and pelvis with oral contrast. During that admission, she was fitted with an ostomy appliance overlying her wound, but continues to leak around her ostomy bag. For this reason she came to the [MASKED] ED. In the ED, she was evaluated by surgical service who felt she was stable for outpatient management, and they temporized the leaking of the ostomy. In the ED, initial vitals were: 98.0 [MASKED] 18 100% RA - Exam notable for: Tachycardic Stool leaking around inferior and lower right edges of appliance. Area of purulence on left - Labs notable for: [MASKED] 00:22 Lactate:1.5 [MASKED] 00:05 [MASKED]: 13.5 PTT: 27.8 INR: 1.2 Urinalysis: contaminated w/epis 138 101 13 ============<105 4.0 23 0.6 10.0<9.5/30.5>313 [MASKED] - Imaging was notable for: [MASKED]: CXR Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded, particularly in the appropriate clinical setting. - ACS was consulted: noted that ostomy looked good, no need for inpatient admission - Patient was given: 1L NS - Vitals prior to transfer: 88 103/40 16 97% RA Upon arrival to the floor, patient reports she has had a cough since her surgery, denies fever, chills, abdominal pain, chest pain, nausea, vomiting, other symptoms. Past Medical History: PMH: [MASKED] disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in [MASKED] (last SBO), right shoulder dislocation s/ p repair [MASKED] Social History: [MASKED] Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISSION EXAM Vital Signs: 98.2 112 / 70 95 18 94 RA General: Alert, oriented, fatigued appearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. CV: Mild tachycardia. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, diminished bilateral bases. Abdomen: Distended, non-tender on deep palpation, +bowel sounds. Patient w/surgical site covered in newly placed vac covered by ostomy bag. This was placed a few hours prior to exam and stool is leaking around the vac. GU: No foley Ext: Warm, well perfused Neuro: gait deferred Discharge Physical Exam: Vitals - Pertinent Results: ADMISSION LABS [MASKED] 08:20PM BLOOD WBC-10.0 RBC-3.47* Hgb-9.5* Hct-30.5* MCV-88 MCH-27.4 MCHC-31.1* RDW-15.6* RDWSD-50.3* Plt [MASKED] [MASKED] 08:20PM BLOOD Neuts-60.7 [MASKED] Monos-12.9 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-6.09 AbsLymp-2.59 AbsMono-1.30* AbsEos-0.01* AbsBaso-0.02 [MASKED] 08:20PM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-23 AnGap-18 [MASKED] 08:20PM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 [MASKED] 12:22AM BLOOD Lactate-1.5 RADIOLOGY [MASKED] Imaging CHEST (PA & LAT) FINDINGS: The lungs appear hypoinflated. Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded. Linear opacities in the left lung likely represent atelectasis. There is no pulmonary edema or pneumothorax. The cardiomediastinal silhouette and hilar contours are exaggerated by low lung volumes but appear unchanged. IMPRESSION: Opacities in the right lung base may represent atelectasis, however, aspiration or infection cannot be entirely excluded, particularly in the appropriate clinical setting. BD & PELVIS WITH CO IMPRESSION: 1. There is large irregular peripherally enhancing air-fluid collection right lower quadrant, below the cecum, abutting anterior abdominal wall, consistent with abscess. 2. Findings concerning for leak at the level of the umbilicus, with high-density material likely representing enteric contrast that has extravasated, and enterocutaneous fistula covered by a wound VAC. 3. Hepatic steatosis. CT ABD & PELVIS WITH CONTRASTStudy Date of [MASKED] 4:47 [MASKED] IMPRESSION: 1. Marked interval decrease in the size of the previously seen large abscess in the right lower quadrant, now a shallow collection of gas and fluid measuring up to 1.6 cm in greatest thickness. This collection is too small for a drain to be placed. The previously placed pigtail catheter is retracted and located within the anterior abdominal wall. 2. The patient's known anterior abdominal wall enterocutaneous fistula is incompletely evaluated in the absence of oral contrast but appears overall similar compared to prior studies. There is no evidence of obstruction. No new fluid collections are seen. Brief Hospital Course: [MASKED] y/o F hx of [MASKED] disease, syringomyelia, and SBO in [MASKED], s/p exploratory laparotomy, lysis of adhesions and small bowel resection (90 cm) with primary anastomosis (no ostomy) on [MASKED] by Dr. [MASKED] presenting w/ongoing enterocutaneous fistula and leakage around ostomy bag along a new enterocutanous fistula with hypotension and tachycardia. Hypotension was thought to be from increased ostomy output and improved with IV fluid resuscitation. Surgery saw the patient and noted that she had a new, enterocutaneous fistula. A wound vac was placed. The thought was that this would improve the dynamics of the drainage from the current enterocutaneous fistula. A CT scan was performed which was reviewed with the surgical team. Upon review, a fluid collection was demonstrated. At this time the patient was transferred to the surgical service for [MASKED] guided drainage. Of note, there was initial concern for pneumonia upon presentation and the patient received a dose of doxycycline given her allergies. This was discontinued as upon further review, it was not determined that the patient had a pneumonia. On Hospital Day 2, the patient went to Interventional Radiology for placement for a drain for the RLQ abdominal abscess. She was started on broad-spectrum IV antibiotics for the fluid collection as well as positive blood culture, although this was likely a contaminant as further blood cultures were negative. She was seen by wound [MASKED] nursing staff who placed a pouch appliance for the entero-cutaneous fistula. The enterocutaneous fistula continued to put out ~500cc/day and was put to gravity. The pouch was resealed and replaced several times during her hospital course. The patient's IV antibiotics were narrowed to IV ceftazidime for cultures growing pansensitive E coli. The patient refused to take any other oral or IV antibiotics. She worked with Physical Therapy during her hospital stay which cleared her for home after a few more sessions, which were done. On Hospital Day 7, the patient's [MASKED] drain was noted to have slipped out several inches, and so a CT abdomen/pelvis w/ PO/IV contrast was obtained which demonstrated the drain was located in the subcutaneous tissue and the RLQ abdominal fluid collection still present but slightly smaller in size. Interventional Radiology then replaced the drain. The patient was hospitalized for several more days to ensure the ostomy appliance was not leaking with movement. At this point, the patient had completed her 7-day course of antibiotics and was ready for discharge home with [MASKED] for wound care and weekly clinic visit with the wound care clinic. She was ready for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Cyclobenzaprine 5 mg PO TID:PRN spasm 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 4. LORazepam 1 mg PO DAILY:PRN anxiety 5. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: ENTEROCUTANEOUS FISTULA Abdominal fluid collection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to the hospital because you were having leaking from your chronic abdominal wound. You were seen by our surgical team who placed a wound vac to help alleviate the pressure on this wound. We repeated a CAT scan of your abdomen, which demonstrated an abdominal abscess. This was drained by Interventional Radiology and you were started on IV antibiotics. You were transferred to the Surgery Service for further care. The wound care/ostomy nurses have changed your ostomy appliance several times during your hospitalization to best exclude the enterocutaneous fistula and incorporate it as part of your wound care. You currently have [MASKED] pouch. You were continued on IV antibiotics which were narrowed based on your drain culture results. You have now completed your course of antibiotics. Your drain slipped out a few inches and a repeat CT scan was obtained to assist Interventional Radiology in replacing your drain. Your drain was replaced successfully and your pouch has been holding for 48 hours since its last replacement. You are now ready for discharge home with nursing care for your [MASKED] drain as well as ostomy pouch. You no longer require further antibiotics. Your discharge medications and follow up appointments are detailed below. Please follow the below instructions for a safe and speedy recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. We wish you the best! Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "Y929" ]
[ "K632: Fistula of intestine", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "K651: Peritoneal abscess", "G950: Syringomyelia and syringobulbia", "I959: Hypotension, unspecified", "D680: Von Willebrand's disease", "I272: Other secondary pulmonary hypertension", "K9403: Colostomy malfunction", "Y833: Surgical operation with formation of external stoma 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", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere" ]
10,063,848
26,880,153
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Attending: ___. Chief Complaint: Fistula Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ who presented with prior SBO now 3 weeks s/p exploratory laparotomy, lysis of adhesions, and small bowel resection (90 cm) presenting from clinic with concern for small bowel erosion into wound bed without signs of fistulous development. Mrs. ___ was discharged home with services, as she declined rehab placement, on ___ and presented to her follow up appointment today where her vac dressing was taken down, revealing small bowel serosa per report. Therefore, she was sent to the ED for plans to admit for wound management. Past Medical History: PMH: ___ disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in ___ (last SBO), right shoulder dislocation s/ p repair ___ Social History: ___ Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISISON EXAM ------------------- Vitals: 96.9 93 100/48 16 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese, nontender, no rebound or guarding, midline wound open with two discrete areas of fascial dehiscence superiorly and inferiorly; the inferior aspect of the wound display frank feculent output Ext: No ___ edema, ___ warm and well perfused WOUND NURSE EXAM ___ Stoma Assessment: Type of Ostomy: Colostomy ( ) Ileostomy( ) Urostomy ( ) Fistula ( X ) Wound: 15 x 5 x 5.5 cm EC fistula opening in inferior wound bed 3 x 2 x 5.5 cm EC fistula not stomatized Superior wound opening 6 x 3 x 2 cm Wound bed: pink, granular Edges: attached Periwound: intact, no erythema, no induration Exudate; from fistula, milky brown Odor: drainage with malodor pain; with cleansing DISCHARGE EXAM ------------------- Vitals: 98.7 ___ GEN: AOx3, NAD HEENT: No scleral icterus, moist mucous membranes CV: RRR PULM: Clear to auscultation b/l ABD: Soft, midline wound open with two areas of fascial dehiscence superiorly and inferiorly. Ostomy device in place. Ext: No ___ edema Pertinent Results: Hematology COMPLETE BLOOD COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt Ct ___ 04:42AM 8.73.13*8.7*28.0*9027.831.1*15.249.3*183 ___ 05:35AM 6.62.95*8.2*26.5*9027.830.9*15.149.0*171 ___ 01:17PM 9.83.37*9.3*30.3*9027.630.7*15.350.3*208 DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso ___ 01:17PM 56.3 27.513.9*0.8*0.6 0.9*5.492.691.36*0.080.06 BASIC COAGULATION ___, PTT, PLT, INR)Plt Ct ___ 04:42AM 183 ___ 05:35AM 171 ___ 01:17PM 208 Chemistry RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap ___ 04:42AM ___ ___ 05:35AM ___ ___ 02:48PM ___ ___ 01:17PM ___ CHEMISTRYTotProtAlbuminGlobulnCalciumPhosMgUricAcdIron ___ 04:42AM 7.9*3.11.8 ___ 05:35AM 8.3*3.62.2 ___ 02:48PM 8.2*3.62.0 Blood Gas WHOLE BLOOD, MISCELLANEOUS CHEMISTRYLactate ___ 01:33PM 1.6Import Result ___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:00PM URINE RBC-4* WBC-0 Bacteri-FEW Yeast-NONE Epi-3 ___ 05:00PM URINE Mucous-FEW ___ 5:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ---------- ___ CT ABD & PELVIS WITH CO 1. Midline dehiscence of the abdominal wall; caudally it extends into the peritoneal cavity where a 2.5 cm focus of (organizing fluid) is demonstrated just deep to the dehiscence (2:68, 601b:20, 602b:40). 2. Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. ___ consider CT abdomen and pelvis with oral contrast if this will alter management. 3. Focal dilatation of the small bowel loop proximal to the anastomosis could be secondary to postoperative ileus or partial/early small bowel obstruction with the anastomosis site serving as the transition point. 4. Fatty liver. RECOMMENDATION(S): Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. ___ consider CT abdomen and pelvis with oral contrast if this will alter management. Brief Hospital Course: ___ 3 weeks s/p exploratory laparotomy with small bowel resection presented with foul smelling feculent discharge from her wound with areas concerning for fascial dehiscence and enterocutaneous fistula. # Entero-cutaneous fistula: # Fascial Dehiscence: On presentation, exam was concerning for feculence in wound. CT scan was notable for fascial dehiscence at the wound site and also there was concern for an anastomotic leak. On HD 2, a methylene blue test was done confirming an enterocutaneous fistula. Patient was seen by the wound care nurse and fitted with an ostomy appliance over her open wound and EC fistula. She was set up with home ___ to assist with dressing changes and was provided teaching on her ostomy device. Prior to discharge patient's pain was controlled, she was tolerating a regular diet, and patient was ammenable to ___ services and caring for her new ostomy appliance. TRANSITIONAL ISSUES [] will need re-assessment of wound by Dr. ___ in one week. [] Patient discharged with ostomy appliance with ___ for home dressing changes. WOUND CARE RECOMMENDATIONS Equipment:one piece drainable ( ) one piece convex drainable ( ) two piece drainable ___ ( ) two piece drainable ___ ( ) one piece urostomy ( ) two piece urostomy ___ ( ) two piece urostomy ___ ( ) Supplies: Coloplast mini wound ___ ___ # ___ ___ # ___ Coloplast paste strips PS# ___ ___ # ___ Instructions: Pouch change twice weekly ___ or for leakage cleanse wounds with Commercial wound cleanser set on spray and pat dry with dry gauze, remove all cleanser cleanse periwound with warm water using disposable wash cloths, pat dry (template with patient) trace pouch opening Apply paste strips to pouch opening and mold in Apply pouch to abdomen, use hot packs to activate seal Attach window Use air pump to inflate bolster Close drain tap Empty pouch when ___ full Monitor output and pouch integrity closely Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 3. LOPERamide 2 mg PO QID:PRN diarrhea 4. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. LOPERamide 2 mg PO QID:PRN diarrhea 3. Metoprolol Succinate XL 25 mg PO DAILY 4. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you speak with your primary care doctor. Has increased risk for ulcers/bleeding Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Surgical Wound with an Entero-cutaneous Fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You presented to the hospital with small bowel eroding into your wound. You were admitted to the hospital for wound management. In the hospital, - A methylene blue test revealed that you have a fistula in your wound, which is leaking enteric content (small bowel content). - You were seen by our wound care specialist. - An ostomy appliance was placed to help with wound healing and help prevent infections. - You received teaching to care for your wound. - ___ was set up to help mange your wound. When you leave the hospital - Record your Ostomy output daily. When it is ___ full, empty the pouch. - If the Ostomy output starts to increase significantly, call your MD and/or seek medical attention. - If you develop fevers, chills, nausea, worsening abdominal pain, or other concerning symptoms seek medical attention. Further "Danger Signs" are listed for you in this document. For your reference, we have provided dressing change instructions for you. It was a pleasure taking care of you, -Your ___ Care Team. CARE INSTRUCTIONS 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 and should continue to walk several times a day. 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 10 lbs until cleared by your surgeon. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children. 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/showers 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 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 You may have sponge baths with covering your ostomy appliance. Pat dry, do not rub. Do not shower, bathe, soak, or swim until cleared by your surgeon o You may gently wash away dried material around your incision. o Avoid direct sun exposure to your wound. o Do not use any ointments on the incision unless you were told otherwise. 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 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 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: ___
[ "K632", "T8131XA", "Y832", "Y929" ]
Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Chief Complaint: Fistula Major Surgical or Invasive Procedure: NONE History of Present Illness: [MASKED] who presented with prior SBO now 3 weeks s/p exploratory laparotomy, lysis of adhesions, and small bowel resection (90 cm) presenting from clinic with concern for small bowel erosion into wound bed without signs of fistulous development. Mrs. [MASKED] was discharged home with services, as she declined rehab placement, on [MASKED] and presented to her follow up appointment today where her vac dressing was taken down, revealing small bowel serosa per report. Therefore, she was sent to the ED for plans to admit for wound management. Past Medical History: PMH: [MASKED] disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in [MASKED] (last SBO), right shoulder dislocation s/ p repair [MASKED] Social History: [MASKED] Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISISON EXAM ------------------- Vitals: 96.9 93 100/48 16 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese, nontender, no rebound or guarding, midline wound open with two discrete areas of fascial dehiscence superiorly and inferiorly; the inferior aspect of the wound display frank feculent output Ext: No [MASKED] edema, [MASKED] warm and well perfused WOUND NURSE EXAM [MASKED] Stoma Assessment: Type of Ostomy: Colostomy ( ) Ileostomy( ) Urostomy ( ) Fistula ( X ) Wound: 15 x 5 x 5.5 cm EC fistula opening in inferior wound bed 3 x 2 x 5.5 cm EC fistula not stomatized Superior wound opening 6 x 3 x 2 cm Wound bed: pink, granular Edges: attached Periwound: intact, no erythema, no induration Exudate; from fistula, milky brown Odor: drainage with malodor pain; with cleansing DISCHARGE EXAM ------------------- Vitals: 98.7 [MASKED] GEN: AOx3, NAD HEENT: No scleral icterus, moist mucous membranes CV: RRR PULM: Clear to auscultation b/l ABD: Soft, midline wound open with two areas of fascial dehiscence superiorly and inferiorly. Ostomy device in place. Ext: No [MASKED] edema Pertinent Results: Hematology COMPLETE BLOOD COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt Ct [MASKED] 04:42AM 8.73.13*8.7*28.0*9027.831.1*15.249.3*183 [MASKED] 05:35AM 6.62.95*8.2*26.5*9027.830.9*15.149.0*171 [MASKED] 01:17PM 9.83.37*9.3*30.3*9027.630.7*15.350.3*208 DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso [MASKED] 01:17PM 56.3 27.513.9*0.8*0.6 0.9*5.492.691.36*0.080.06 BASIC COAGULATION [MASKED], PTT, PLT, INR)Plt Ct [MASKED] 04:42AM 183 [MASKED] 05:35AM 171 [MASKED] 01:17PM 208 Chemistry RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap [MASKED] 04:42AM [MASKED] [MASKED] 05:35AM [MASKED] [MASKED] 02:48PM [MASKED] [MASKED] 01:17PM [MASKED] CHEMISTRYTotProtAlbuminGlobulnCalciumPhosMgUricAcdIron [MASKED] 04:42AM 7.9*3.11.8 [MASKED] 05:35AM 8.3*3.62.2 [MASKED] 02:48PM 8.2*3.62.0 Blood Gas WHOLE BLOOD, MISCELLANEOUS CHEMISTRYLactate [MASKED] 01:33PM 1.6Import Result [MASKED] 05:00PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 05:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 05:00PM URINE RBC-4* WBC-0 Bacteri-FEW Yeast-NONE Epi-3 [MASKED] 05:00PM URINE Mucous-FEW [MASKED] 5:00 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ---------- [MASKED] CT ABD & PELVIS WITH CO 1. Midline dehiscence of the abdominal wall; caudally it extends into the peritoneal cavity where a 2.5 cm focus of (organizing fluid) is demonstrated just deep to the dehiscence (2:68, 601b:20, 602b:40). 2. Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. [MASKED] consider CT abdomen and pelvis with oral contrast if this will alter management. 3. Focal dilatation of the small bowel loop proximal to the anastomosis could be secondary to postoperative ileus or partial/early small bowel obstruction with the anastomosis site serving as the transition point. 4. Fatty liver. RECOMMENDATION(S): Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. [MASKED] consider CT abdomen and pelvis with oral contrast if this will alter management. Brief Hospital Course: [MASKED] 3 weeks s/p exploratory laparotomy with small bowel resection presented with foul smelling feculent discharge from her wound with areas concerning for fascial dehiscence and enterocutaneous fistula. # Entero-cutaneous fistula: # Fascial Dehiscence: On presentation, exam was concerning for feculence in wound. CT scan was notable for fascial dehiscence at the wound site and also there was concern for an anastomotic leak. On HD 2, a methylene blue test was done confirming an enterocutaneous fistula. Patient was seen by the wound care nurse and fitted with an ostomy appliance over her open wound and EC fistula. She was set up with home [MASKED] to assist with dressing changes and was provided teaching on her ostomy device. Prior to discharge patient's pain was controlled, she was tolerating a regular diet, and patient was ammenable to [MASKED] services and caring for her new ostomy appliance. TRANSITIONAL ISSUES [] will need re-assessment of wound by Dr. [MASKED] in one week. [] Patient discharged with ostomy appliance with [MASKED] for home dressing changes. WOUND CARE RECOMMENDATIONS Equipment:one piece drainable ( ) one piece convex drainable ( ) two piece drainable [MASKED] ( ) two piece drainable [MASKED] ( ) one piece urostomy ( ) two piece urostomy [MASKED] ( ) two piece urostomy [MASKED] ( ) Supplies: Coloplast mini wound [MASKED] [MASKED] # [MASKED] [MASKED] # [MASKED] Coloplast paste strips PS# [MASKED] [MASKED] # [MASKED] Instructions: Pouch change twice weekly [MASKED] or for leakage cleanse wounds with Commercial wound cleanser set on spray and pat dry with dry gauze, remove all cleanser cleanse periwound with warm water using disposable wash cloths, pat dry (template with patient) trace pouch opening Apply paste strips to pouch opening and mold in Apply pouch to abdomen, use hot packs to activate seal Attach window Use air pump to inflate bolster Close drain tap Empty pouch when [MASKED] full Monitor output and pouch integrity closely Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen [MASKED] mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 3. LOPERamide 2 mg PO QID:PRN diarrhea 4. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen [MASKED] mg PO PRN Pain - Mild 2. LOPERamide 2 mg PO QID:PRN diarrhea 3. Metoprolol Succinate XL 25 mg PO DAILY 4. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you speak with your primary care doctor. Has increased risk for ulcers/bleeding Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Surgical Wound with an Entero-cutaneous Fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You presented to the hospital with small bowel eroding into your wound. You were admitted to the hospital for wound management. In the hospital, - A methylene blue test revealed that you have a fistula in your wound, which is leaking enteric content (small bowel content). - You were seen by our wound care specialist. - An ostomy appliance was placed to help with wound healing and help prevent infections. - You received teaching to care for your wound. - [MASKED] was set up to help mange your wound. When you leave the hospital - Record your Ostomy output daily. When it is [MASKED] full, empty the pouch. - If the Ostomy output starts to increase significantly, call your MD and/or seek medical attention. - If you develop fevers, chills, nausea, worsening abdominal pain, or other concerning symptoms seek medical attention. Further "Danger Signs" are listed for you in this document. For your reference, we have provided dressing change instructions for you. It was a pleasure taking care of you, -Your [MASKED] Care Team. CARE INSTRUCTIONS 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 and should continue to walk several times a day. 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 10 lbs until cleared by your surgeon. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children. 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/showers 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 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 You may have sponge baths with covering your ostomy appliance. Pat dry, do not rub. Do not shower, bathe, soak, or swim until cleared by your surgeon o You may gently wash away dried material around your incision. o Avoid direct sun exposure to your wound. o Do not use any ointments on the incision unless you were told otherwise. 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 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 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]
[]
[ "Y929" ]
[ "K632: Fistula of intestine", "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "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" ]
10,063,856
22,345,354
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Attending: ___. Chief Complaint: Bradycardia and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. The patient states she has been feeling very tired and weak and has had dizziness and lightneadedness when she walks. She has fallen twice recently. She has found by a home health nurse to have a heart rate as low as the ___ and a blood pressure as low as the ___ systolic. She went to her local ED and recieved a dose of atropine and antibiotics and was transferred to the ED here. The patient states that about a week ago she started having some dysuria. In the last couple of days she has had urinary frequency as well. She reports having a UTI a month ago and her symptoms did get better before these started again last week. She denies any fevers, cough, shortness of breath, nausea, or change in ostomy output. REVIEW OF SYSTEMS: - All reviewed and otherwise negative. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in ___ with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to ___ on ___. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on ___ revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on ___. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on ___. 6. Patient completed whole brain radiation therapy on ___. Total dose ___ cGY. 7. Patient was re-admitted at ___ on ___ with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on ___ showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between ___ and ___. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on ___. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on ___. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on ___. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on ___ with improvement in symptoms. Cycle 3 administered on ___. Cycle 4 ___. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: ___ Family History: Mother: ___ degeneration. Father: ___ bowel disease, CVA. Maternal grandfather: CVA. Brother: ___ bowel disease. Sister: DM. Physical Exam: PHYSICAL EXAM: General: NAD VITAL SIGNS: T 97.2 HR 42 BP 95/55 O2 100%RA HEENT: MMM CV: Bradycardia PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly, ostomy present with brown stool output. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: Superficial abrasion to left arm. NEURO: Alert and oriented, no focal deficits. Pertinent Results: ___ 06:35AM GLUCOSE-88 UREA N-13 CREAT-0.7 SODIUM-133 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 ___ 06:35AM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-41 TOT BILI-0.3 ___ 06:35AM cTropnT-<0.01 ___ 06:35AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.7 ___ 06:35AM WBC-6.2 RBC-2.98* HGB-8.8* HCT-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-23.1* RDWSD-76.7* ___ 07:34PM LACTATE-2.0 Portable Chest X-ray ___: IMPRESSION: Persistent left upper lobe collapse without evidence of pneumonia. Decreasing mass, left hilus and left upper lobe. Possible pulmonary metastasis, right lower lobe. This examination neither suggests nor excludes the diagnosis of pulmonary embolism. Brief Hospital Course: ___ yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. Concern for UTI: U/A at ___ concerning for UTI with ___ WBC, ___ RBC, 0 Epis, 2 + bacteria, moderate ___, - nitrites but culture growing mixed bacteria consistent with contamination. U/a and culture here negative. She was initially put on ceftriaxone which was discontinued. C. Diff: C. diff positive with some increased watery ostomy output. Started on PO vancomycin for 14 day course. Hypotension: possibly due to infection, adrenal insufficiency or dehydration. Her baseline systolic blood pressures in clinic appears to be 100-120. She did not appear significantly hypovolemic on examination and infection overall did not appear severe enough to be causing this degree of hypotension. She was placed on stress dose steroids with hydrocortisone with improvement in her blood pressure. She was transitioned back to her home dose of decadron prior to discharge. BP's on day of discharge 120's systolic. Bradycardia: she has chronic sinus bradycardia for years, no changes on ECG, no evidence of conduction disease on telemetry or ECG. She does report increased falls and ? syncopal episode at home. Her bradycardia may be contributing but she is not interested in an intervention such as a pacemaker. TSH normal. Chest pressure: Atypical chest pressure since she fell, likely musculoskeletal (reproducible on exam), no ischemic ECG changes, troponin negative and resolved. Could also be due to lung mets. Thrush Continued home clotrimazole. Metastatic Lung Cancer S/p cycle 4 premetrexed/carboplatin ___. She is finished with carboplatin, per oncology plan to continue with maintenance premetrexed. Continued home atovaquone, dronabinol, folic acid, keppra, ativan, omeprazole, pampazine, and trazadone. FEN: Regular diet PAIN: Continued home oxycontin at night and PRN ultram. DVT PROPHYLAXIS: Heparin 5000 units SC CODE STATUS: - DNR/DNI Pt was discharged back home to resume her already arranged hospice care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LeVETiracetam 500 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. B Complete (vitamin B complex) 0 ORAL DAILY 7. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 8. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Clotrimazole 1 TROC PO QID 13. Atovaquone Suspension 1500 mg PO DAILY 14. Dexamethasone 4 mg PO DAILY 15. Dronabinol 2.5 mg PO BID 16. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D ___ UNIT PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*48 Capsule Refills:*0 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C. difficile infection Adrenal insufficiency 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 with low blood pressure and low heart rates. You were found to have recurrent c. diff and are being treated with Vancomycin by mouth. Your blood pressure improved and you had no further episodes of dizziness. Followup Instructions: ___
[ "E2740", "B9689", "I959", "R001", "R0789", "B379", "C3490", "Z87891", "Z66", "Z934" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Chief Complaint: Bradycardia and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. The patient states she has been feeling very tired and weak and has had dizziness and lightneadedness when she walks. She has fallen twice recently. She has found by a home health nurse to have a heart rate as low as the [MASKED] and a blood pressure as low as the [MASKED] systolic. She went to her local ED and recieved a dose of atropine and antibiotics and was transferred to the ED here. The patient states that about a week ago she started having some dysuria. In the last couple of days she has had urinary frequency as well. She reports having a UTI a month ago and her symptoms did get better before these started again last week. She denies any fevers, cough, shortness of breath, nausea, or change in ostomy output. REVIEW OF SYSTEMS: - All reviewed and otherwise negative. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in [MASKED] with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to [MASKED] on [MASKED]. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on [MASKED] revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on [MASKED]. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on [MASKED]. 6. Patient completed whole brain radiation therapy on [MASKED]. Total dose [MASKED] cGY. 7. Patient was re-admitted at [MASKED] on [MASKED] with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on [MASKED] showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between [MASKED] and [MASKED]. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on [MASKED]. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on [MASKED]. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on [MASKED]. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on [MASKED] with improvement in symptoms. Cycle 3 administered on [MASKED]. Cycle 4 [MASKED]. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: [MASKED] Family History: Mother: [MASKED] degeneration. Father: [MASKED] bowel disease, CVA. Maternal grandfather: CVA. Brother: [MASKED] bowel disease. Sister: DM. Physical Exam: PHYSICAL EXAM: General: NAD VITAL SIGNS: T 97.2 HR 42 BP 95/55 O2 100%RA HEENT: MMM CV: Bradycardia PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly, ostomy present with brown stool output. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: Superficial abrasion to left arm. NEURO: Alert and oriented, no focal deficits. Pertinent Results: [MASKED] 06:35AM GLUCOSE-88 UREA N-13 CREAT-0.7 SODIUM-133 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 [MASKED] 06:35AM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-41 TOT BILI-0.3 [MASKED] 06:35AM cTropnT-<0.01 [MASKED] 06:35AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.7 [MASKED] 06:35AM WBC-6.2 RBC-2.98* HGB-8.8* HCT-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-23.1* RDWSD-76.7* [MASKED] 07:34PM LACTATE-2.0 Portable Chest X-ray [MASKED]: IMPRESSION: Persistent left upper lobe collapse without evidence of pneumonia. Decreasing mass, left hilus and left upper lobe. Possible pulmonary metastasis, right lower lobe. This examination neither suggests nor excludes the diagnosis of pulmonary embolism. Brief Hospital Course: [MASKED] yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. Concern for UTI: U/A at [MASKED] concerning for UTI with [MASKED] WBC, [MASKED] RBC, 0 Epis, 2 + bacteria, moderate [MASKED], - nitrites but culture growing mixed bacteria consistent with contamination. U/a and culture here negative. She was initially put on ceftriaxone which was discontinued. C. Diff: C. diff positive with some increased watery ostomy output. Started on PO vancomycin for 14 day course. Hypotension: possibly due to infection, adrenal insufficiency or dehydration. Her baseline systolic blood pressures in clinic appears to be 100-120. She did not appear significantly hypovolemic on examination and infection overall did not appear severe enough to be causing this degree of hypotension. She was placed on stress dose steroids with hydrocortisone with improvement in her blood pressure. She was transitioned back to her home dose of decadron prior to discharge. BP's on day of discharge 120's systolic. Bradycardia: she has chronic sinus bradycardia for years, no changes on ECG, no evidence of conduction disease on telemetry or ECG. She does report increased falls and ? syncopal episode at home. Her bradycardia may be contributing but she is not interested in an intervention such as a pacemaker. TSH normal. Chest pressure: Atypical chest pressure since she fell, likely musculoskeletal (reproducible on exam), no ischemic ECG changes, troponin negative and resolved. Could also be due to lung mets. Thrush Continued home clotrimazole. Metastatic Lung Cancer S/p cycle 4 premetrexed/carboplatin [MASKED]. She is finished with carboplatin, per oncology plan to continue with maintenance premetrexed. Continued home atovaquone, dronabinol, folic acid, keppra, ativan, omeprazole, pampazine, and trazadone. FEN: Regular diet PAIN: Continued home oxycontin at night and PRN ultram. DVT PROPHYLAXIS: Heparin 5000 units SC CODE STATUS: - DNR/DNI Pt was discharged back home to resume her already arranged hospice care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LeVETiracetam 500 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Vitamin D [MASKED] UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. B Complete (vitamin B complex) 0 ORAL DAILY 7. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 8. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Clotrimazole 1 TROC PO QID 13. Atovaquone Suspension 1500 mg PO DAILY 14. Dexamethasone 4 mg PO DAILY 15. Dronabinol 2.5 mg PO BID 16. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D [MASKED] UNIT PO DAILY 14. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*48 Capsule Refills:*0 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: C. difficile infection Adrenal insufficiency 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 with low blood pressure and low heart rates. You were found to have recurrent c. diff and are being treated with Vancomycin by mouth. Your blood pressure improved and you had no further episodes of dizziness. Followup Instructions: [MASKED]
[]
[ "Z87891", "Z66" ]
[ "E2740: Unspecified adrenocortical insufficiency", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "I959: Hypotension, unspecified", "R001: Bradycardia, unspecified", "R0789: Other chest pain", "B379: Candidiasis, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate", "Z934: Other artificial openings of gastrointestinal tract status" ]
10,063,856
29,364,646
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Attending: ___ Chief Complaint: Lightheadness, shaking, near fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/metastatic lung CA, last chemo ___, who presents with lightheadedness. Pt was admitted ___ after with sinus bradycardia to ___, SBP to ___, with presyncopal episodes at home. No interventions in house, patient declined interventions such as pacemaker. Etiology unclear, negative troponins in house. She was found to have C. diff while in house, started on 14 day PO Vancomyocin course. This morning was walking with a walker, entire body felt tremulous and she felt lightheaded. Called for her husband who lowered her to the ground. No headstrike or LOC. Later in the afternoon ___ attempted a standing BP and she felt similar symptoms, no LOC or headstrike. No HAs. No fevers chills or cough. Has been having constant CP and mild exertional dyspnea for 2 weeks after a fall (had negative cardiac enzymes and EKGs last admission). Pt has ileostomy (s/p C diff colitis), output has not been increased since discharge. No vomiting. The lightheadedness feel similar to her recent admission symptoms, however the tremors/weakness are new and what concerns her most. In the ED, initial VS were: 97.8 55 133/75 19 95% RA Labs were notable for: lactate 2.7, K 3.1, Ca: 9.1 Mg: 1.4 P: 2.5, wbc ct 3.2 (___ ___), h/h 8.8/26.7, platelets 124. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in ___ with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to ___ on ___. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on ___ revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on ___. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on ___. 6. Patient completed whole brain radiation therapy on ___. Total dose ___ cGY. 7. Patient was re-admitted at ___ on ___ with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on ___ showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between ___ and ___. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on ___. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on ___. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on ___. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on ___ with improvement in symptoms. Cycle 3 administered on ___. Cycle 4 ___. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: ___ Family History: Mother: ___ degeneration. Father: ___ bowel disease, CVA. Maternal grandfather: CVA. Brother: ___ bowel disease. Sister: DM. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== GENERAL: NAD HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: T98.0 | ___ | 112/75-132/70 | 16 | 98% RA General: NAD. Pleasant, A+O x3. HEENT: MMM. Balding. No OP lesions. CV: RRR, NL S1/S2 no murmurs. Markedly decreased pain with palpation over and around sternum. PULM: Clear GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Has ostomy with brown liquid stool LIMBS: No edema SKIN: No rashes or skin breakdown NEURO: Oriented, ___ strength upper and lower extremities Pertinent Results: ================ ADMISSION LABS: ================ ___ 02:30PM BLOOD WBC-3.2* RBC-2.92* Hgb-8.8* Hct-26.7* MCV-91 MCH-30.1 MCHC-33.0 RDW-22.6* RDWSD-74.2* Plt ___ ___ 02:30PM BLOOD Neuts-67.3 ___ Monos-6.4 Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.10 AbsLymp-0.78* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00* ___ 02:30PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-137 K-3.1* Cl-98 HCO3-27 AnGap-15 ___ 02:30PM BLOOD ALT-77* AST-58* AlkPhos-40 TotBili-0.2 ___ 02:30PM BLOOD Lipase-37 ___ 02:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:10AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:30PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.5* Mg-1.4* ___ 02:32PM BLOOD Lactate-2.7* ___ 01:38PM BLOOD Lactate-3.0* ___ 11:15AM BLOOD Lactate-2.4* ___ 08:10AM BLOOD Cortsol-0.4* ___ 08:30AM BLOOD VitB12-908* ================= DISCHARGE LABS: ================= ___ 07:55AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.6* Hct-26.6* MCV-96 MCH-31.0 MCHC-32.3 RDW-24.4* RDWSD-80.9* Plt ___ ___ 07:55AM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-29 AnGap-12 ___ 07:45AM BLOOD ALT-80* AST-37 LD(LDH)-264* AlkPhos-44 TotBili-0.2 ___ 07:55AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.8 ============ KEY IMAGING: ============ ___ MRI Head w/,w/o contrast:FINDINGS: Since the prior study, there has been interval appearance of multiple foci with diffusion weighted signal intensity in the right frontal lobe (502:24, 25), some of which correspond to associated FLAIR signal intensity (07:19, 20). A single focus of left frontal peripheral diffusion-weighted hyperintense signal is also new (series 502, image 72). Another tiny focus of right parietal cortical FLAIR/diffusion signal hyperintensity also demonstrates postcontrast enhancement (502:20, 7:16, 10:16), and is also new since the prior study. Otherwise, known enhancing lesions in the infratentorial brain are stable compared to the prior study, and include a lower left cerebellar hemispheric lesion (900:24), anterior inferior right cerebellar hemisphere lesion (900:28), and an 11 x 8 mm medial left cerebellar hemispheric lesion (900:41). Other supratentorial lesions previously described are also stable, including a left occipital lesion (10:14), anterior right frontal lobe lesion (10:18), and an 8 mm left temporal lobe lesion (900:54). Punctate hemorrhagic foci are stable in the left parietal and posterior right frontal and anterior right frontal lobes. No new hemorrhage is identified. There is no shift of the normally midline structures. Ventricles and sulci remain unchanged in size and configuration. The major intracranial vascular flow voids are preserved, and the major dural venous sinuses appear patent. The paranasal sinuses are clear. The orbits are unremarkable. The left mastoid air cells are clear. IMPRESSION: 1. Multiple new right frontal cortical foci in a single left frontal focus of likely reflect sites of acute/subacute infarction of embolic origin, given distribution and small size and rapid development since prior examination of ___. However, in the context of known metastatic disease, underlying malignancy cannot be completely excluded. 2. A similar tiny focus in the right parietal cortex exhibits mild enhancement. Likely etiology is again acute/subacute infarction, but malignancy cannot be excluded. 3. Numerous other supra and infratentorial metastatic lesions are stable since the recent prior study, as described above. RECOMMENDATION(S): 1. Continued follow-up imaging is recommended for findings described in IMPRESSION #'s 1 and 2. Brief Hospital Course: ___ with stage IV lung cancer with known brain mets s/p cycle 4 of pemetrexed/carboplatin (last cycle ___ who is admitted with 2 episodes of "shaking" and weakness at home, found to have new brain lesions. ============== ACTIVE ISSUES: ============== # Lightheadedness/Shaking episode: Possible presyncope with hypotension vs. seizure. Seizures initially felt unlikely as patient maintained consciousness and could recall the entire episode and with bland inpatient EEG. However, MRI brain showed new lesions that may represent embolic infarcts vs. new metastatic foci. Neuro-oncology was consulted and proposed seizure on stroke impact as unifying explanation of patient's presentation. Orthostasis or weakness/muscle spasm due to electrolyte derrangements also considered, but no significant hypotension or electrolyte abnormalities documented at time of hospitalization. Over 48 hours of continuous telemetry showed no atrial fibrillation. During hospitalization, increased Keppra from 500mg bid to ___ BID. Started aspirin 81mg daily for secondary stroke prevention. Home dexamethasone was continued. Full stroke workup was deferred as it was felt unlikely to change patient's management and invasive/intensive testing was not consistent with patient's goals of care. # Headaches: Patient was awoken by ___ bifrontal headache on at least two nights. No associated neurological signs or symptoms. Head imaging showed new findings as above but no acute change in edema or other culprits for increased intracranial pressure. Got tramadol with some relief, later patient was transitioned to dilaudid and long-acting analgesics were up-titrated with no further complaint of headaches. # Chest pain: Present for several weeks prior to admission, intermittent. Pleuritic with deep inspiration and exacerbated by movement, straining. Reproducible w/ palpation. Most likely secondary to metastatic disease affecting bones of chest wall, as demonstrated by prior imaging. Treated symptomatically with increased long-acting opioid plus dilaudid prn with good relief. # Back pain: Has been chronic. MRI T/L spine showed benign appearing T10 compression fracture. Neurosurgery consulted and recommended Soft TLSO brace for activity and HOB>45 degrees. Pain control as above. # Vulvovaginal Candiadiasis: Recurrent issue for patient. Of note, patient is allergic to fluconazole. Started Miconazole Vaginal suppository for ___ased on symptom resolution. Patient noted significant improvement in symptoms and miconazole was discontinued at discharge. # Thrombocytopenia: Platelets decreased to 75 on ___, counts have been lower than prior. Likely chemotherapy effect with recent carboplatin exposure. Platelets began to increased on ___ and had improved by discharge. =============== CHRONIC ISSUES: =============== # Anemia: likely due to chemotherapy and inflammatory block in setting of malignancy. Hemoglobin largely stable since recent admission and continued to be stable while inpatient. No history of bleeding or melena. # Metastatic lung cancer: s/p cycle 4 premetrexed/carboplatin (last ___. Held chemotherapy while inpatient. Further chemotherapy would be palliative and can be restarted at the discretion of the primary oncology team. # C. Difficile: C. diff positive on ___ with some increased watery ostomy output. Started on PO vancomycin for 14 day course on ___, which was continued while inpatient. Patient was maintained on contact precautions. Plan to continue PO vancomycin until ___. ==================== TRANSITIONAL ISSUES: ==================== CODE STATUS: DNR/DNI, confirmed CONTACT: husband/HCP ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D ___ UNIT PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Dexamethasone 4 mg PO DAILY 3. Dronabinol 2.5 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. LeVETiracetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 6. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Vitamin D ___ UNIT PO DAILY 13. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*4 14. B Complete (vitamin B complex) 1 tablet ORAL DAILY 15. Clotrimazole 1 TROC PO QID 16. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 17. Vancomycin Oral Liquid ___ mg PO Q6H Last day ___ 18. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6) hours Disp #*112 Tablet Refills:*0 19. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7 Days RX *miconazole nitrate [Miconazole 7] 2 % 1 app VG at bedtime Disp #*1 Package Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - Metastatic Lung Cancer - Brain lesions, infarct versus metastatic disease - Compression fracture, T10 vertebra SECONDARY DIAGNOSES: - Candidiasis, vulvovaginal - C. difficile colitis, on treatment - Ulcerative colitis 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 ___, ___ was a pleasure to care for ___ here at ___. ___ were admitted after an episode of shaking and nearly falling down at home. While we can't be certain exactly what happened, we believe ___ may have had a seizure due to small strokes or brain metastatic lesions. We also cannot rule out near fainting from low blood pressure. During your hospital stay, ___ had no seizures or episodes of low blood pressure. ___ remained steady on your feet while walking. During your hospitalization, imaging studies showed possible new strokes in your brain or progression of metastases in your brain. Imaging of your back showed a benign compression fracture of the T10 vertebral bone. This is most likely the cause of your back pain. It is not related to your cancer. The chest pain ___ had is most likely a result of lung cancer. All of this pain was controlled with some strong pain medicines that we will give ___ at discharge. ___ will have follow up appointments with oncology and your other doctors. ___ have more imaging studies scheduled to assess how your cancer is progressing. Your Keppra dose was increased. Thank ___ for letting us participate in your care, Your ___ team Followup Instructions: ___
[ "I6340", "C7951", "I9589", "E873", "C7931", "K5190", "D696", "M4854XA", "I4891", "B373", "D638", "B9689", "E876", "K219", "G43009", "N6009", "M722", "E890", "E8342", "Z932" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Chief Complaint: Lightheadness, shaking, near fall Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/metastatic lung CA, last chemo [MASKED], who presents with lightheadedness. Pt was admitted [MASKED] after with sinus bradycardia to [MASKED], SBP to [MASKED], with presyncopal episodes at home. No interventions in house, patient declined interventions such as pacemaker. Etiology unclear, negative troponins in house. She was found to have C. diff while in house, started on 14 day PO Vancomyocin course. This morning was walking with a walker, entire body felt tremulous and she felt lightheaded. Called for her husband who lowered her to the ground. No headstrike or LOC. Later in the afternoon [MASKED] attempted a standing BP and she felt similar symptoms, no LOC or headstrike. No HAs. No fevers chills or cough. Has been having constant CP and mild exertional dyspnea for 2 weeks after a fall (had negative cardiac enzymes and EKGs last admission). Pt has ileostomy (s/p C diff colitis), output has not been increased since discharge. No vomiting. The lightheadedness feel similar to her recent admission symptoms, however the tremors/weakness are new and what concerns her most. In the ED, initial VS were: 97.8 55 133/75 19 95% RA Labs were notable for: lactate 2.7, K 3.1, Ca: 9.1 Mg: 1.4 P: 2.5, wbc ct 3.2 ([MASKED] [MASKED]), h/h 8.8/26.7, platelets 124. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in [MASKED] with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to [MASKED] on [MASKED]. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on [MASKED] revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on [MASKED]. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on [MASKED]. 6. Patient completed whole brain radiation therapy on [MASKED]. Total dose [MASKED] cGY. 7. Patient was re-admitted at [MASKED] on [MASKED] with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on [MASKED] showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between [MASKED] and [MASKED]. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on [MASKED]. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on [MASKED]. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on [MASKED]. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on [MASKED] with improvement in symptoms. Cycle 3 administered on [MASKED]. Cycle 4 [MASKED]. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: [MASKED] Family History: Mother: [MASKED] degeneration. Father: [MASKED] bowel disease, CVA. Maternal grandfather: CVA. Brother: [MASKED] bowel disease. Sister: DM. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== GENERAL: NAD HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: T98.0 | [MASKED] | 112/75-132/70 | 16 | 98% RA General: NAD. Pleasant, A+O x3. HEENT: MMM. Balding. No OP lesions. CV: RRR, NL S1/S2 no murmurs. Markedly decreased pain with palpation over and around sternum. PULM: Clear GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Has ostomy with brown liquid stool LIMBS: No edema SKIN: No rashes or skin breakdown NEURO: Oriented, [MASKED] strength upper and lower extremities Pertinent Results: ================ ADMISSION LABS: ================ [MASKED] 02:30PM BLOOD WBC-3.2* RBC-2.92* Hgb-8.8* Hct-26.7* MCV-91 MCH-30.1 MCHC-33.0 RDW-22.6* RDWSD-74.2* Plt [MASKED] [MASKED] 02:30PM BLOOD Neuts-67.3 [MASKED] Monos-6.4 Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-2.10 AbsLymp-0.78* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00* [MASKED] 02:30PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-137 K-3.1* Cl-98 HCO3-27 AnGap-15 [MASKED] 02:30PM BLOOD ALT-77* AST-58* AlkPhos-40 TotBili-0.2 [MASKED] 02:30PM BLOOD Lipase-37 [MASKED] 02:30PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 08:10AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 02:30PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.5* Mg-1.4* [MASKED] 02:32PM BLOOD Lactate-2.7* [MASKED] 01:38PM BLOOD Lactate-3.0* [MASKED] 11:15AM BLOOD Lactate-2.4* [MASKED] 08:10AM BLOOD Cortsol-0.4* [MASKED] 08:30AM BLOOD VitB12-908* ================= DISCHARGE LABS: ================= [MASKED] 07:55AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.6* Hct-26.6* MCV-96 MCH-31.0 MCHC-32.3 RDW-24.4* RDWSD-80.9* Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-29 AnGap-12 [MASKED] 07:45AM BLOOD ALT-80* AST-37 LD(LDH)-264* AlkPhos-44 TotBili-0.2 [MASKED] 07:55AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.8 ============ KEY IMAGING: ============ [MASKED] MRI Head w/,w/o contrast:FINDINGS: Since the prior study, there has been interval appearance of multiple foci with diffusion weighted signal intensity in the right frontal lobe (502:24, 25), some of which correspond to associated FLAIR signal intensity (07:19, 20). A single focus of left frontal peripheral diffusion-weighted hyperintense signal is also new (series 502, image 72). Another tiny focus of right parietal cortical FLAIR/diffusion signal hyperintensity also demonstrates postcontrast enhancement (502:20, 7:16, 10:16), and is also new since the prior study. Otherwise, known enhancing lesions in the infratentorial brain are stable compared to the prior study, and include a lower left cerebellar hemispheric lesion (900:24), anterior inferior right cerebellar hemisphere lesion (900:28), and an 11 x 8 mm medial left cerebellar hemispheric lesion (900:41). Other supratentorial lesions previously described are also stable, including a left occipital lesion (10:14), anterior right frontal lobe lesion (10:18), and an 8 mm left temporal lobe lesion (900:54). Punctate hemorrhagic foci are stable in the left parietal and posterior right frontal and anterior right frontal lobes. No new hemorrhage is identified. There is no shift of the normally midline structures. Ventricles and sulci remain unchanged in size and configuration. The major intracranial vascular flow voids are preserved, and the major dural venous sinuses appear patent. The paranasal sinuses are clear. The orbits are unremarkable. The left mastoid air cells are clear. IMPRESSION: 1. Multiple new right frontal cortical foci in a single left frontal focus of likely reflect sites of acute/subacute infarction of embolic origin, given distribution and small size and rapid development since prior examination of [MASKED]. However, in the context of known metastatic disease, underlying malignancy cannot be completely excluded. 2. A similar tiny focus in the right parietal cortex exhibits mild enhancement. Likely etiology is again acute/subacute infarction, but malignancy cannot be excluded. 3. Numerous other supra and infratentorial metastatic lesions are stable since the recent prior study, as described above. RECOMMENDATION(S): 1. Continued follow-up imaging is recommended for findings described in IMPRESSION #'s 1 and 2. Brief Hospital Course: [MASKED] with stage IV lung cancer with known brain mets s/p cycle 4 of pemetrexed/carboplatin (last cycle [MASKED] who is admitted with 2 episodes of "shaking" and weakness at home, found to have new brain lesions. ============== ACTIVE ISSUES: ============== # Lightheadedness/Shaking episode: Possible presyncope with hypotension vs. seizure. Seizures initially felt unlikely as patient maintained consciousness and could recall the entire episode and with bland inpatient EEG. However, MRI brain showed new lesions that may represent embolic infarcts vs. new metastatic foci. Neuro-oncology was consulted and proposed seizure on stroke impact as unifying explanation of patient's presentation. Orthostasis or weakness/muscle spasm due to electrolyte derrangements also considered, but no significant hypotension or electrolyte abnormalities documented at time of hospitalization. Over 48 hours of continuous telemetry showed no atrial fibrillation. During hospitalization, increased Keppra from 500mg bid to [MASKED] BID. Started aspirin 81mg daily for secondary stroke prevention. Home dexamethasone was continued. Full stroke workup was deferred as it was felt unlikely to change patient's management and invasive/intensive testing was not consistent with patient's goals of care. # Headaches: Patient was awoken by [MASKED] bifrontal headache on at least two nights. No associated neurological signs or symptoms. Head imaging showed new findings as above but no acute change in edema or other culprits for increased intracranial pressure. Got tramadol with some relief, later patient was transitioned to dilaudid and long-acting analgesics were up-titrated with no further complaint of headaches. # Chest pain: Present for several weeks prior to admission, intermittent. Pleuritic with deep inspiration and exacerbated by movement, straining. Reproducible w/ palpation. Most likely secondary to metastatic disease affecting bones of chest wall, as demonstrated by prior imaging. Treated symptomatically with increased long-acting opioid plus dilaudid prn with good relief. # Back pain: Has been chronic. MRI T/L spine showed benign appearing T10 compression fracture. Neurosurgery consulted and recommended Soft TLSO brace for activity and HOB>45 degrees. Pain control as above. # Vulvovaginal Candiadiasis: Recurrent issue for patient. Of note, patient is allergic to fluconazole. Started Miconazole Vaginal suppository for ased on symptom resolution. Patient noted significant improvement in symptoms and miconazole was discontinued at discharge. # Thrombocytopenia: Platelets decreased to 75 on [MASKED], counts have been lower than prior. Likely chemotherapy effect with recent carboplatin exposure. Platelets began to increased on [MASKED] and had improved by discharge. =============== CHRONIC ISSUES: =============== # Anemia: likely due to chemotherapy and inflammatory block in setting of malignancy. Hemoglobin largely stable since recent admission and continued to be stable while inpatient. No history of bleeding or melena. # Metastatic lung cancer: s/p cycle 4 premetrexed/carboplatin (last [MASKED]. Held chemotherapy while inpatient. Further chemotherapy would be palliative and can be restarted at the discretion of the primary oncology team. # C. Difficile: C. diff positive on [MASKED] with some increased watery ostomy output. Started on PO vancomycin for 14 day course on [MASKED], which was continued while inpatient. Patient was maintained on contact precautions. Plan to continue PO vancomycin until [MASKED]. ==================== TRANSITIONAL ISSUES: ==================== CODE STATUS: DNR/DNI, confirmed CONTACT: husband/HCP [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D [MASKED] UNIT PO DAILY 14. Vancomycin Oral Liquid [MASKED] mg PO Q6H 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Dexamethasone 4 mg PO DAILY 3. Dronabinol 2.5 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. LeVETiracetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 6. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Vitamin D [MASKED] UNIT PO DAILY 13. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*4 14. B Complete (vitamin B complex) 1 tablet ORAL DAILY 15. Clotrimazole 1 TROC PO QID 16. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 17. Vancomycin Oral Liquid [MASKED] mg PO Q6H Last day [MASKED] 18. HYDROmorphone (Dilaudid) [MASKED] mg PO Q6H:PRN pain RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*112 Tablet Refills:*0 19. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7 Days RX *miconazole nitrate [Miconazole 7] 2 % 1 app VG at bedtime Disp #*1 Package Refills:*3 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: - Metastatic Lung Cancer - Brain lesions, infarct versus metastatic disease - Compression fracture, T10 vertebra SECONDARY DIAGNOSES: - Candidiasis, vulvovaginal - C. difficile colitis, on treatment - Ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure to care for [MASKED] here at [MASKED]. [MASKED] were admitted after an episode of shaking and nearly falling down at home. While we can't be certain exactly what happened, we believe [MASKED] may have had a seizure due to small strokes or brain metastatic lesions. We also cannot rule out near fainting from low blood pressure. During your hospital stay, [MASKED] had no seizures or episodes of low blood pressure. [MASKED] remained steady on your feet while walking. During your hospitalization, imaging studies showed possible new strokes in your brain or progression of metastases in your brain. Imaging of your back showed a benign compression fracture of the T10 vertebral bone. This is most likely the cause of your back pain. It is not related to your cancer. The chest pain [MASKED] had is most likely a result of lung cancer. All of this pain was controlled with some strong pain medicines that we will give [MASKED] at discharge. [MASKED] will have follow up appointments with oncology and your other doctors. [MASKED] have more imaging studies scheduled to assess how your cancer is progressing. Your Keppra dose was increased. Thank [MASKED] for letting us participate in your care, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "D696", "I4891", "K219" ]
[ "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "C7951: Secondary malignant neoplasm of bone", "I9589: Other hypotension", "E873: Alkalosis", "C7931: Secondary malignant neoplasm of brain", "K5190: Ulcerative colitis, unspecified, without complications", "D696: Thrombocytopenia, unspecified", "M4854XA: Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture", "I4891: Unspecified atrial fibrillation", "B373: Candidiasis of vulva and vagina", "D638: Anemia in other chronic diseases classified elsewhere", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "E876: Hypokalemia", "K219: Gastro-esophageal reflux disease without esophagitis", "G43009: Migraine without aura, not intractable, without status migrainosus", "N6009: Solitary cyst of unspecified breast", "M722: Plantar fascial fibromatosis", "E890: Postprocedural hypothyroidism", "E8342: Hypomagnesemia", "Z932: Ileostomy status" ]
10,063,991
25,007,733
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Voice weakness, facial weakness and difficulty walking Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. ___ is a ___ yo M w/no significant PMHx who presents with acute onset L> right facial weakness, nasal voice, ophthalmoplegia, and vertical diplopia in setting of recent campylobacter infection. 2 weeks ago patient had diarrheal illness, confirmed campylobacter at ___, and was prescribed an antibiotic. Diarrhea resolved. ___ he began having paresthesias of left face. He felt his voice was weak. ___ he noted his voice had a nasal quality, his vision felt "off", he had transient tingling in his hands, and began experiencing vertical diplopia when trying to look up. He also is intermittently having the feeling fluids are coming back up through his nostrils when drinking. He was admitted to ___ where he had a MR head w/out acute abnormalities. LP on ___ with 13 RBC, 3 WBC, 54 protein, 43 glucose. He was evaluated by SLP who said he was safe to eat. NIF/VC monitored and he never reported difficulty breathing or shortness of breath. As he thought his symptoms had plateaud and he wanted to go back home to his wife and child, he was discharged from ___ ___. He walked home and felt off and light headed the walk back. This AM when he woke up, his eyes felt heavier and he represented to ___ ED. On neuro ROS, the pt has slight headache around his temples. Denies loss of vision,dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. Past Medical History: None Social History: ___ Family History: Unknown, patient adopted. Physical Exam: Admission Physical Exam ======================= Vitals: T: 98, BP: 118/70 HR 52 RR 16 02 96% RA NIF: less than -60 General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: warm and well perfused Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. 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. Speech is not dysarthric but has nasal quality. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction of right eye. Normal saccades. V: Facial sensation intact to light touch. VII: L>R ptosis, weakness of left eye closure, smile symmetric VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: LT 80% of normal on ___ outer thighs, but normal on PP. No DSS. -DTRs: Bi Tri ___ Pat Ach L 0 1 1 0 0 R 0 1 1 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. ' Discharge Physical Exam ======================== General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: Audible S1 and S2. RRR. No rubs/murmurs/gallops Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert. Language is fluent. Normal prosody. Speech is not dysarthric but has nasal quality. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction, however able to cross midline. On upgaze, right eye able to easily cross midline about 30 degrees, left eye only barely able to cross midline. Able to fully adduct on individual testing. V: Facial sensation intact to light touch. VII: Able to rise eyebrows, shut eyes, puff cheeks and smile. Forced eye closure on the left was slightly weaker than the right, but only on confrontation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: Symmetrical bilaterally to light touch. -DTRs: Bi Tri Bracioradialis Pat L 0 0 0 0 R 2 2 0 0 -Coordination: No intention tremor. Normal finger to nose. -Gait: appears normal but slow, pt states that he feels weak in left knee Pertinent Results: Admission Lab Results ===================== ___ 03:41PM BLOOD WBC-6.2 RBC-4.65 Hgb-13.9 Hct-41.9 MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 RDWSD-43.7 Plt ___ ___ 03:41PM BLOOD Neuts-64.6 ___ Monos-5.1 Eos-2.1 Baso-1.4* Im ___ AbsNeut-4.02 AbsLymp-1.65 AbsMono-0.32 AbsEos-0.13 AbsBaso-0.09* ___ 03:41PM BLOOD ___ PTT-37.1* ___ ___ 03:41PM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-145 K-3.9 Cl-109* HCO3-23 AnGap-13 ___ 03:41PM BLOOD ALT-17 AST-13 AlkPhos-40 TotBili-0.8 ___ 03:41PM BLOOD cTropnT-<0.01 ___ 03:41PM BLOOD TotProt-6.5 Albumin-4.0 Globuln-2.5 Discharge Lab Results ===================== None collected on the day of discharge Imaging ======= MRI orbits: IMPRESSION: 1. No imaging evidence for optic neuritis or other orbital abnormalities. 2. No evidence abnormal enhancement along the cranial nerves. Unremarkable appearance of the cavernous sinuses. 3. No evidence for dural venous sinus thrombosis. 4. No evidence for intracranial mass or acute intracranial abnormalities. Specifically, no signal abnormalities in the brainstem. 5. Right frontal developmental venous anomaly. Brief Hospital Course: Mr. ___ is a ___ y/o previously healthy male who developed voice weakness, facial weakness, ataxia and bilateral hand numbness iso recent campylobacter infection. Patient LP at OSH on ___ with 13 RBC, 3 WBC, 54 protein, 43 glucose. The CSF likely was drawn early, resulting in lack of the albuminocytologic dissociation likely due to LP being drawn within one week of onset of symptoms. He was completed a 5 day course of IVIG with some improvement in his symptoms. There was no evidence of respiratory compromise during this admission. One interesting finding was the presence of red color desaturation during his admission. Given that this is likely not c/w MF GBS, an MRI was performed which did not reveal any evidence of optic neuritis or other pathology that might explain this phenomenon. The finding was not present on later exams, and was perhaps spurious. He remained stable if not with some slight improvement in his left CN3 palsy. He had return of biceps and triceps reflex on his right hand (___). remaining reflexes 0. He was discharged with planned neurology followup. Transitional Issues =================== [] GQ1b Antibodies pending [ ] Neurology f/u within ___ months, we will call to schedule. If you do not hear, call ___ to schedule. Medications on Admission: Flonase prn Discharge Medications: Flonase prn Discharge Disposition: Home Discharge Diagnosis: ___ variant of Guillian ___ syndrome Discharge Condition: Alert and Oriented to person, place and time. Vital signs stable. Discharge Instructions: It was a pleasure taking care of you at ___. You were admitted to ___ given the constellation of your symptoms including facial weakness, voice weakness and difficulty walking. These symptoms, in addition to your physical exam findings of absent reflexes and impaired vertical gaze is consistent with a subtype of Guillian ___ Syndrome called ___ Syndrome. This likely occurred as a result of your immune system's reaction to your recent diarrheal illness. We treated you with intravenous immunoglobulin and your symptoms showed some gradual improvement. We expect that this will continue over the coming weeks and months. We also monitored your breathing and there were no concerns with your respiratory status. To help confirm our diagnosis, we ruled out other possible causes for your weakness with an MRI. You were discharged in stable condition. Please follow-up with ___ Neurology as scheduled. Thank you for allowing us to participate in your care, ___ Neurology Followup Instructions: ___
[ "G610", "H532" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Voice weakness, facial weakness and difficulty walking Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. [MASKED] is a [MASKED] yo M w/no significant PMHx who presents with acute onset L> right facial weakness, nasal voice, ophthalmoplegia, and vertical diplopia in setting of recent campylobacter infection. 2 weeks ago patient had diarrheal illness, confirmed campylobacter at [MASKED], and was prescribed an antibiotic. Diarrhea resolved. [MASKED] he began having paresthesias of left face. He felt his voice was weak. [MASKED] he noted his voice had a nasal quality, his vision felt "off", he had transient tingling in his hands, and began experiencing vertical diplopia when trying to look up. He also is intermittently having the feeling fluids are coming back up through his nostrils when drinking. He was admitted to [MASKED] where he had a MR head w/out acute abnormalities. LP on [MASKED] with 13 RBC, 3 WBC, 54 protein, 43 glucose. He was evaluated by SLP who said he was safe to eat. NIF/VC monitored and he never reported difficulty breathing or shortness of breath. As he thought his symptoms had plateaud and he wanted to go back home to his wife and child, he was discharged from [MASKED] [MASKED]. He walked home and felt off and light headed the walk back. This AM when he woke up, his eyes felt heavier and he represented to [MASKED] ED. On neuro ROS, the pt has slight headache around his temples. Denies loss of vision,dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. Past Medical History: None Social History: [MASKED] Family History: Unknown, patient adopted. Physical Exam: Admission Physical Exam ======================= Vitals: T: 98, BP: 118/70 HR 52 RR 16 02 96% RA NIF: less than -60 General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: warm and well perfused Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. 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. Speech is not dysarthric but has nasal quality. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction of right eye. Normal saccades. V: Facial sensation intact to light touch. VII: L>R ptosis, weakness of left eye closure, smile symmetric VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] 5 [MASKED] 5 5 5 5 5 R 5 [MASKED] 5 [MASKED] 5 5 5 5 5 -Sensory: LT 80% of normal on [MASKED] outer thighs, but normal on PP. No DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 0 1 1 0 0 R 0 1 1 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. ' Discharge Physical Exam ======================== General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: Audible S1 and S2. RRR. No rubs/murmurs/gallops Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert. Language is fluent. Normal prosody. Speech is not dysarthric but has nasal quality. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction, however able to cross midline. On upgaze, right eye able to easily cross midline about 30 degrees, left eye only barely able to cross midline. Able to fully adduct on individual testing. V: Facial sensation intact to light touch. VII: Able to rise eyebrows, shut eyes, puff cheeks and smile. Forced eye closure on the left was slightly weaker than the right, but only on confrontation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 -Sensory: Symmetrical bilaterally to light touch. -DTRs: Bi Tri Bracioradialis Pat L 0 0 0 0 R 2 2 0 0 -Coordination: No intention tremor. Normal finger to nose. -Gait: appears normal but slow, pt states that he feels weak in left knee Pertinent Results: Admission Lab Results ===================== [MASKED] 03:41PM BLOOD WBC-6.2 RBC-4.65 Hgb-13.9 Hct-41.9 MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 RDWSD-43.7 Plt [MASKED] [MASKED] 03:41PM BLOOD Neuts-64.6 [MASKED] Monos-5.1 Eos-2.1 Baso-1.4* Im [MASKED] AbsNeut-4.02 AbsLymp-1.65 AbsMono-0.32 AbsEos-0.13 AbsBaso-0.09* [MASKED] 03:41PM BLOOD [MASKED] PTT-37.1* [MASKED] [MASKED] 03:41PM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-145 K-3.9 Cl-109* HCO3-23 AnGap-13 [MASKED] 03:41PM BLOOD ALT-17 AST-13 AlkPhos-40 TotBili-0.8 [MASKED] 03:41PM BLOOD cTropnT-<0.01 [MASKED] 03:41PM BLOOD TotProt-6.5 Albumin-4.0 Globuln-2.5 Discharge Lab Results ===================== None collected on the day of discharge Imaging ======= MRI orbits: IMPRESSION: 1. No imaging evidence for optic neuritis or other orbital abnormalities. 2. No evidence abnormal enhancement along the cranial nerves. Unremarkable appearance of the cavernous sinuses. 3. No evidence for dural venous sinus thrombosis. 4. No evidence for intracranial mass or acute intracranial abnormalities. Specifically, no signal abnormalities in the brainstem. 5. Right frontal developmental venous anomaly. Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o previously healthy male who developed voice weakness, facial weakness, ataxia and bilateral hand numbness iso recent campylobacter infection. Patient LP at OSH on [MASKED] with 13 RBC, 3 WBC, 54 protein, 43 glucose. The CSF likely was drawn early, resulting in lack of the albuminocytologic dissociation likely due to LP being drawn within one week of onset of symptoms. He was completed a 5 day course of IVIG with some improvement in his symptoms. There was no evidence of respiratory compromise during this admission. One interesting finding was the presence of red color desaturation during his admission. Given that this is likely not c/w MF GBS, an MRI was performed which did not reveal any evidence of optic neuritis or other pathology that might explain this phenomenon. The finding was not present on later exams, and was perhaps spurious. He remained stable if not with some slight improvement in his left CN3 palsy. He had return of biceps and triceps reflex on his right hand ([MASKED]). remaining reflexes 0. He was discharged with planned neurology followup. Transitional Issues =================== [] GQ1b Antibodies pending [ ] Neurology f/u within [MASKED] months, we will call to schedule. If you do not hear, call [MASKED] to schedule. Medications on Admission: Flonase prn Discharge Medications: Flonase prn Discharge Disposition: Home Discharge Diagnosis: [MASKED] variant of Guillian [MASKED] syndrome Discharge Condition: Alert and Oriented to person, place and time. Vital signs stable. Discharge Instructions: It was a pleasure taking care of you at [MASKED]. You were admitted to [MASKED] given the constellation of your symptoms including facial weakness, voice weakness and difficulty walking. These symptoms, in addition to your physical exam findings of absent reflexes and impaired vertical gaze is consistent with a subtype of Guillian [MASKED] Syndrome called [MASKED] Syndrome. This likely occurred as a result of your immune system's reaction to your recent diarrheal illness. We treated you with intravenous immunoglobulin and your symptoms showed some gradual improvement. We expect that this will continue over the coming weeks and months. We also monitored your breathing and there were no concerns with your respiratory status. To help confirm our diagnosis, we ruled out other possible causes for your weakness with an MRI. You were discharged in stable condition. Please follow-up with [MASKED] Neurology as scheduled. Thank you for allowing us to participate in your care, [MASKED] Neurology Followup Instructions: [MASKED]
[]
[]
[ "G610: Guillain-Barre syndrome", "H532: Diplopia" ]
10,064,049
22,000,239
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, fatigue, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with hx Afib w/ RVR, MDS RAEB ___ s/p RIC (Flu/Bu) MRD alloSCT D+293 on ___, post transplant course notable for pure red cell aplasia (required CSA taper, resulted in gut & skin GVHD), aspergillus pneumonia (now posaconazole ppx), recent admit for GNR CLABSI s/p 14 days cipro (dig held in setting of ___, now admitted from clinic for a-fib with RVR to 120s in clinic, +15 lb weight gain over 2 weeks. Patient complains of fatigue for the last couple of days. He also notes shortness of breath mainly upon exertion and going up the stairs. He reports bilateral leg edema and weight gain of ___ pounds, and denies cough, wheezing, chest pain, fever, chills. This is not the first time it happens to him, but he does not recall taking diuretics to treat fluid overload at home. During his visit at the clinic today, he was found to be clinically fluid overloaded so he was given Lasix 20 IV in clinic and was admitted for obeservation. LVEF =64% on echo ___. Past Medical History: PAST ONCOLOGIC HISTORY: BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seenin MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: ___: C1 Decitabine ___: C2 Decitabine ___: C3 Decitabine ___: C4 Decitabine ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL ADDITIONAL TREATMENT: ___: C1: IVIG ___: C2: IVIG PAST MEDICAL/SURGICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD s/p EGD -s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ON ADMISSION: Vitals: Tc 97.3 HR 120 BP 114/86 RR 22 SaO2 ra Weight: 190.5 Gen: Pleasant, calm, weak but nontoxic HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclav LAD CV: Tachycardic, irregular rhythm. No MRG. LUNGS: No incr WOB. Mild decrease in air entry in bases bilaterally. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: Bilateral pitting edema +1 SKIN: No rashes/lesions, petechiae/purpura. NEURO: A&Ox3. LINES: Peripheral IV ON DISCHARGE: Vitals: Tc 97.7 HR 90-100's BP ___ RR 18 SaO2 98% Weight: 180 lbs (compared to 190 lbs on admission) Gen: Pleasant, calm, weak but nontoxic HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclav LAD CV: Irregular rhythm, non tachycardic, No MRG. LUNGS: No incr WOB. Mild decrease in air entry in bases bilaterally. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: Bilateral pitting edema +1 SKIN: No rashes/lesions, petechiae/purpura. NEURO: A&Ox3. LINES: Peripheral IV Pertinent Results: ON ADMISSION: ___ 10:00AM BLOOD WBC-8.6 RBC-2.19* Hgb-8.9* Hct-26.6* MCV-122* MCH-40.6* MCHC-33.5 RDW-18.9* RDWSD-83.3* Plt Ct-93* ___ 10:00AM BLOOD Neuts-87* Bands-0 ___ Monos-11 Eos-0 Baso-2* ___ Myelos-0 NRBC-1* AbsNeut-7.48* AbsLymp-0.00* AbsMono-0.95* AbsEos-0.00* AbsBaso-0.17* ___ 10:00AM BLOOD ___ PTT-24.1* ___ ___ 10:00AM BLOOD Ret Aut-4.3* Abs Ret-0.09 ___ 10:00AM BLOOD UreaN-46* Creat-1.5* Na-132* K-4.4 Cl-96 HCO3-29 AnGap-11 ___ 10:00AM BLOOD ALT-48* AST-35 LD(LDH)-459* AlkPhos-134* TotBili-0.6 ___ 10:00AM BLOOD cTropnT-0.03* ___ ___ 10:00AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2 UricAcd-5.8 ___ 10:00AM BLOOD VitB12-296 Hapto-177 ___ 10:00AM BLOOD Cyclspr-169 ON DISCHARGE: ___ 06:50AM BLOOD WBC-4.9 RBC-2.20* Hgb-8.8* Hct-25.7* MCV-117* MCH-40.0* MCHC-34.2 RDW-18.4* RDWSD-76.8* Plt Ct-62* ___ 06:50AM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-7 Eos-0 Baso-0 ___ Myelos-1* NRBC-4* AbsNeut-4.17 AbsLymp-0.34* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00* ___ 06:50AM BLOOD Glucose-128* UreaN-35* Creat-1.3* Na-131* K-4.0 Cl-95* HCO3-30 AnGap-10 ___ 06:25AM BLOOD ALT-34 AST-27 LD(LDH)-418* AlkPhos-101 TotBili-0.7 ___ 06:50AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 UricAcd-6.7 PERTINENT TESTS: ___ ECHO: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate (___) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Right ventricular cavity dilation. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation and tricuspid regurgitation have increased. The right ventricle was mildly dilated on review of the prior study. ___ ECHO: The left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF =64%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Mild aortic regurgitation. Compared with the prior study (images reviewed) of ___, the findings are similar. ___ CXR: No focal consolidation, pleural effusion or pneumothorax is present. No acute osseous abnormality is detected. IMPRESSION: No acute cardiopulmonary abnormality. ___ ECG: Atrial fibrillation with rapid ventricular response. Delayed R wave transition. Compared to the previous tracing of ___ no diagnostic interim change. Brief Hospital Course: ___ year old male with history of persistent Afib with rapid ventricular rate, MDS RAEB ___ s/p RIC (Flu/Bu) MRD alloSCT D+293 on ___, post transplant course notable for pure red cell aplasia (required CSA taper, resulted in gut & skin GVHD), aspergillus pneumonia (now posaconazole ppx), recent admit for GNR CLABSI s/p 14 days cipro (dig held in setting of ___, now admitted from clinic for a-fib with RVR to 120s in clinic (sx: only fatigue), +15 lb weight gain over 2 weeks. #Afib w/ RVR: Patient with history of persistent AF, on home diltiazem ER 240 mg capsule, metoprolol succinate ER 50 mg, and aspirin (Digoxin recently D/C due to ___. Urine analysis, urine culture, and blood culture are normal. TSH within normal limits. Patient's medications were changed as follows with appropriate rate control to 90-100's: diltiazem ER decreased to 180 mg, metoprolol succinate increased from 50 to 100 mg daily, and digoxin started at a dose of 0.125 mg daily. We continued aspirin for stroke prevention (CHADS score=2). #Heart failure: The symptoms of weight gain of 15 pounds, bilateral lower extremity edema, SOB on exertion, and fatigue in context of preserved ejection fraction are consistent with diastolic heart failure. BNP found to be ___ which is much more elevated than prior (1600). Multifactorial HF: anemia, tachyarrhythmia, prednisone treatment. Patient clinically improved after diuresis (adequate diuresis with 20 mg IV furosemide), with dry weight of 180 lbs on discharge. ___: Patient was also found to have elevated creatinine to 1.5 on ___ compared to a baseline of 1 to 1.1, likely cardio-renal. Creatinine improved after diuresis (creatinine 1.3 on discharge). #MDS RAEB TYPE ___ s/p ALLO D+293 on ___. According to clinic notes, he continues to have a reticulocytosis and it's possible that he is having a low grade microangiopathy in setting of CSA. We continued prophylaxis with acyclovir, atovaquone, posaconazole, ursodiol. Patient is found to have downtrending platelets counts. #GVHD (gut and skin): We decreased prednisone to 15 mg this week then plan to taper down next week to 10 mg. We continued cyclosporine, budesonide for gut GVHD, simethicone PRN gas and distension, and topical triamcinolone for skin GVHD as per OP Dermatology. #ID: He received early course of meropenem followed by cefepime and eventually was transitioned to oral ciprofloxacin for presumed catheter-associated bloodstream infection with citrobacter freundii complex. Tunneled line removed ___ per ___ (blood culture from ___ with no growth). We stopped ciprofloxacin because patient completed full course of antibiotics. #Hypogammaglobulinemia: Patient received IVIG during this admission. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 3. Acyclovir 400 mg PO Q8H 4. Atovaquone Suspension 1500 mg PO DAILY 5. Budesonide 3 mg PO TID 6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 7. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 8. FoLIC Acid 5 mg PO DAILY 9. Lorazepam 0.5-1 mg PO QHS:PRN anxiety, nausea 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Posaconazole Delayed Release Tablet 300 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. Simethicone 40-80 mg PO QID:PRN gas/bloating 15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 16. Ursodiol 300 mg PO BID 17. Vitamin D ___ UNIT PO DAILY 18. copper gluconate 2 mg oral DAILY 19. Diltiazem Extended-Release 240 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Metoprolol Succinate XL 50 mg PO DAILY 22. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 23. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Atovaquone Suspension 1500 mg PO DAILY 5. Budesonide 3 mg PO TID 6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 7. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 8. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID Swish and Spit 9. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 10. FoLIC Acid 5 mg PO DAILY 11. Lorazepam 0.5-1 mg PO QHS:PRN anxiety, nausea 12. Magnesium Oxide 400 mg PO BID 13. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 14. PredniSONE 15 mg PO DAILY RX *prednisone 5 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 15. Vitamin D ___ UNIT PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Pantoprazole 40 mg PO Q12H 18. Posaconazole Delayed Release Tablet 300 mg PO DAILY 19. Simethicone 40-80 mg PO QID:PRN gas/bloating 20. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 21. Ursodiol 300 mg PO BID 22. Digoxin 0.125 mg PO DAILY Afib RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 23. Oxymetazoline 1 SPRY NU BID:PRN Congestion Duration: 3 Days RX *oxymetazoline [Afrin (oxymetazoline)] 0.05 % 1 spray intranasally twice a day as needed Disp #*1 Spray Refills:*0 24. copper gluconate 2 mg oral DAILY 25. Outpatient Lab Work ICD 9 CODE: ___ NAME/CONTACT INFORMATION: ___, ___ Associate, ___ ___ LAB TESTS: Metabolic panel, Digoxin level Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Acute diastolic heart failure Atrial fibrillation Acute kidney injury SECONDARY DIAGNOSES: MDS RAEB TYPE ___ GVHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you have been experiencing fatigue, legs swelling, and shortness of breath on exertion and was found to have a rapid heart rate and increased weight in the ___ clinic. Your symptoms of shortness of breath and weight gain are consistent with a condition called "heart failure", in which the heart is unable to function appropriately so fluid backs up into the lungs and legs, causing respiratory symptoms and leg swelling. We treated you with the diuretic Lasix and you got better. The cause for the heart failure is multifactorial and can be related to the rapid heart rate you were experiencing as well as the anemia. The rapid heart rate is consistent with atrial fibrillation, for which you have been already taking medications. We did adjustments to your medications: we started digoxin, decreased dose of diltiazem, and increased dose of metoprolol. Your heart rate is now within appropriate range. You need to follow up with your cardiologist as scheduled to make sure your heart rate is controlled and the medications dose is adequate. Make sure to adhere to a low salt diet and weigh yourself every day. If you notice that your weight increased by 3 to 4 pounds or your legs are swollen, then take one tablet of Lasix 20 mg. Please inform your cardiologist if your weight keeps on increasing, legs are increasingly swelling, or you become short of breath. It was a pleasure taking care of you! -Your ___ team Followup Instructions: ___
[ "I5031", "N179", "D89813", "T865", "D46Z", "D801", "I481", "R000", "Z7952", "Z7982", "K219", "Z87891", "Z85828", "Z8701", "G4730", "Z803", "Z801" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Shortness of breath, fatigue, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with hx Afib w/ RVR, MDS RAEB [MASKED] s/p RIC (Flu/Bu) MRD alloSCT D+293 on [MASKED], post transplant course notable for pure red cell aplasia (required CSA taper, resulted in gut & skin GVHD), aspergillus pneumonia (now posaconazole ppx), recent admit for GNR CLABSI s/p 14 days cipro (dig held in setting of [MASKED], now admitted from clinic for a-fib with RVR to 120s in clinic, +15 lb weight gain over 2 weeks. Patient complains of fatigue for the last couple of days. He also notes shortness of breath mainly upon exertion and going up the stairs. He reports bilateral leg edema and weight gain of [MASKED] pounds, and denies cough, wheezing, chest pain, fever, chills. This is not the first time it happens to him, but he does not recall taking diuretics to treat fluid overload at home. During his visit at the clinic today, he was found to be clinically fluid overloaded so he was given Lasix 20 IV in clinic and was admitted for obeservation. LVEF =64% on echo [MASKED]. Past Medical History: PAST ONCOLOGIC HISTORY: BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seenin MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: [MASKED]: C1 Decitabine [MASKED]: C2 Decitabine [MASKED]: C3 Decitabine [MASKED]: C4 Decitabine [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL ADDITIONAL TREATMENT: [MASKED]: C1: IVIG [MASKED]: C2: IVIG PAST MEDICAL/SURGICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD s/p EGD -s/p inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ON ADMISSION: Vitals: Tc 97.3 HR 120 BP 114/86 RR 22 SaO2 ra Weight: 190.5 Gen: Pleasant, calm, weak but nontoxic HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclav LAD CV: Tachycardic, irregular rhythm. No MRG. LUNGS: No incr WOB. Mild decrease in air entry in bases bilaterally. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: Bilateral pitting edema +1 SKIN: No rashes/lesions, petechiae/purpura. NEURO: A&Ox3. LINES: Peripheral IV ON DISCHARGE: Vitals: Tc 97.7 HR 90-100's BP [MASKED] RR 18 SaO2 98% Weight: 180 lbs (compared to 190 lbs on admission) Gen: Pleasant, calm, weak but nontoxic HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclav LAD CV: Irregular rhythm, non tachycardic, No MRG. LUNGS: No incr WOB. Mild decrease in air entry in bases bilaterally. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: Bilateral pitting edema +1 SKIN: No rashes/lesions, petechiae/purpura. NEURO: A&Ox3. LINES: Peripheral IV Pertinent Results: ON ADMISSION: [MASKED] 10:00AM BLOOD WBC-8.6 RBC-2.19* Hgb-8.9* Hct-26.6* MCV-122* MCH-40.6* MCHC-33.5 RDW-18.9* RDWSD-83.3* Plt Ct-93* [MASKED] 10:00AM BLOOD Neuts-87* Bands-0 [MASKED] Monos-11 Eos-0 Baso-2* [MASKED] Myelos-0 NRBC-1* AbsNeut-7.48* AbsLymp-0.00* AbsMono-0.95* AbsEos-0.00* AbsBaso-0.17* [MASKED] 10:00AM BLOOD [MASKED] PTT-24.1* [MASKED] [MASKED] 10:00AM BLOOD Ret Aut-4.3* Abs Ret-0.09 [MASKED] 10:00AM BLOOD UreaN-46* Creat-1.5* Na-132* K-4.4 Cl-96 HCO3-29 AnGap-11 [MASKED] 10:00AM BLOOD ALT-48* AST-35 LD(LDH)-459* AlkPhos-134* TotBili-0.6 [MASKED] 10:00AM BLOOD cTropnT-0.03* [MASKED] [MASKED] 10:00AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2 UricAcd-5.8 [MASKED] 10:00AM BLOOD VitB12-296 Hapto-177 [MASKED] 10:00AM BLOOD Cyclspr-169 ON DISCHARGE: [MASKED] 06:50AM BLOOD WBC-4.9 RBC-2.20* Hgb-8.8* Hct-25.7* MCV-117* MCH-40.0* MCHC-34.2 RDW-18.4* RDWSD-76.8* Plt Ct-62* [MASKED] 06:50AM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-7 Eos-0 Baso-0 [MASKED] Myelos-1* NRBC-4* AbsNeut-4.17 AbsLymp-0.34* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00* [MASKED] 06:50AM BLOOD Glucose-128* UreaN-35* Creat-1.3* Na-131* K-4.0 Cl-95* HCO3-30 AnGap-10 [MASKED] 06:25AM BLOOD ALT-34 AST-27 LD(LDH)-418* AlkPhos-101 TotBili-0.7 [MASKED] 06:50AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 UricAcd-6.7 PERTINENT TESTS: [MASKED] ECHO: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([MASKED]) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Right ventricular cavity dilation. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of [MASKED], the severity of mitral regurgitation and tricuspid regurgitation have increased. The right ventricle was mildly dilated on review of the prior study. [MASKED] ECHO: The left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF =64%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [MASKED], the findings are similar. [MASKED] CXR: No focal consolidation, pleural effusion or pneumothorax is present. No acute osseous abnormality is detected. IMPRESSION: No acute cardiopulmonary abnormality. [MASKED] ECG: Atrial fibrillation with rapid ventricular response. Delayed R wave transition. Compared to the previous tracing of [MASKED] no diagnostic interim change. Brief Hospital Course: [MASKED] year old male with history of persistent Afib with rapid ventricular rate, MDS RAEB [MASKED] s/p RIC (Flu/Bu) MRD alloSCT D+293 on [MASKED], post transplant course notable for pure red cell aplasia (required CSA taper, resulted in gut & skin GVHD), aspergillus pneumonia (now posaconazole ppx), recent admit for GNR CLABSI s/p 14 days cipro (dig held in setting of [MASKED], now admitted from clinic for a-fib with RVR to 120s in clinic (sx: only fatigue), +15 lb weight gain over 2 weeks. #Afib w/ RVR: Patient with history of persistent AF, on home diltiazem ER 240 mg capsule, metoprolol succinate ER 50 mg, and aspirin (Digoxin recently D/C due to [MASKED]. Urine analysis, urine culture, and blood culture are normal. TSH within normal limits. Patient's medications were changed as follows with appropriate rate control to 90-100's: diltiazem ER decreased to 180 mg, metoprolol succinate increased from 50 to 100 mg daily, and digoxin started at a dose of 0.125 mg daily. We continued aspirin for stroke prevention (CHADS score=2). #Heart failure: The symptoms of weight gain of 15 pounds, bilateral lower extremity edema, SOB on exertion, and fatigue in context of preserved ejection fraction are consistent with diastolic heart failure. BNP found to be [MASKED] which is much more elevated than prior (1600). Multifactorial HF: anemia, tachyarrhythmia, prednisone treatment. Patient clinically improved after diuresis (adequate diuresis with 20 mg IV furosemide), with dry weight of 180 lbs on discharge. [MASKED]: Patient was also found to have elevated creatinine to 1.5 on [MASKED] compared to a baseline of 1 to 1.1, likely cardio-renal. Creatinine improved after diuresis (creatinine 1.3 on discharge). #MDS RAEB TYPE [MASKED] s/p ALLO D+293 on [MASKED]. According to clinic notes, he continues to have a reticulocytosis and it's possible that he is having a low grade microangiopathy in setting of CSA. We continued prophylaxis with acyclovir, atovaquone, posaconazole, ursodiol. Patient is found to have downtrending platelets counts. #GVHD (gut and skin): We decreased prednisone to 15 mg this week then plan to taper down next week to 10 mg. We continued cyclosporine, budesonide for gut GVHD, simethicone PRN gas and distension, and topical triamcinolone for skin GVHD as per OP Dermatology. #ID: He received early course of meropenem followed by cefepime and eventually was transitioned to oral ciprofloxacin for presumed catheter-associated bloodstream infection with citrobacter freundii complex. Tunneled line removed [MASKED] per [MASKED] (blood culture from [MASKED] with no growth). We stopped ciprofloxacin because patient completed full course of antibiotics. #Hypogammaglobulinemia: Patient received IVIG during this admission. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 3. Acyclovir 400 mg PO Q8H 4. Atovaquone Suspension 1500 mg PO DAILY 5. Budesonide 3 mg PO TID 6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 7. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 8. FoLIC Acid 5 mg PO DAILY 9. Lorazepam 0.5-1 mg PO QHS:PRN anxiety, nausea 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Posaconazole Delayed Release Tablet 300 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. Simethicone 40-80 mg PO QID:PRN gas/bloating 15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 16. Ursodiol 300 mg PO BID 17. Vitamin D [MASKED] UNIT PO DAILY 18. copper gluconate 2 mg oral DAILY 19. Diltiazem Extended-Release 240 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Metoprolol Succinate XL 50 mg PO DAILY 22. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 23. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Atovaquone Suspension 1500 mg PO DAILY 5. Budesonide 3 mg PO TID 6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 7. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 8. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID Swish and Spit 9. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 10. FoLIC Acid 5 mg PO DAILY 11. Lorazepam 0.5-1 mg PO QHS:PRN anxiety, nausea 12. Magnesium Oxide 400 mg PO BID 13. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 14. PredniSONE 15 mg PO DAILY RX *prednisone 5 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 15. Vitamin D [MASKED] UNIT PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Pantoprazole 40 mg PO Q12H 18. Posaconazole Delayed Release Tablet 300 mg PO DAILY 19. Simethicone 40-80 mg PO QID:PRN gas/bloating 20. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 21. Ursodiol 300 mg PO BID 22. Digoxin 0.125 mg PO DAILY Afib RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 23. Oxymetazoline 1 SPRY NU BID:PRN Congestion Duration: 3 Days RX *oxymetazoline [Afrin (oxymetazoline)] 0.05 % 1 spray intranasally twice a day as needed Disp #*1 Spray Refills:*0 24. copper gluconate 2 mg oral DAILY 25. Outpatient Lab Work ICD 9 CODE: [MASKED] NAME/CONTACT INFORMATION: [MASKED], [MASKED] Associate, [MASKED] [MASKED] LAB TESTS: Metabolic panel, Digoxin level Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Acute diastolic heart failure Atrial fibrillation Acute kidney injury SECONDARY DIAGNOSES: MDS RAEB TYPE [MASKED] GVHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you have been experiencing fatigue, legs swelling, and shortness of breath on exertion and was found to have a rapid heart rate and increased weight in the [MASKED] clinic. Your symptoms of shortness of breath and weight gain are consistent with a condition called "heart failure", in which the heart is unable to function appropriately so fluid backs up into the lungs and legs, causing respiratory symptoms and leg swelling. We treated you with the diuretic Lasix and you got better. The cause for the heart failure is multifactorial and can be related to the rapid heart rate you were experiencing as well as the anemia. The rapid heart rate is consistent with atrial fibrillation, for which you have been already taking medications. We did adjustments to your medications: we started digoxin, decreased dose of diltiazem, and increased dose of metoprolol. Your heart rate is now within appropriate range. You need to follow up with your cardiologist as scheduled to make sure your heart rate is controlled and the medications dose is adequate. Make sure to adhere to a low salt diet and weigh yourself every day. If you notice that your weight increased by 3 to 4 pounds or your legs are swollen, then take one tablet of Lasix 20 mg. Please inform your cardiologist if your weight keeps on increasing, legs are increasingly swelling, or you become short of breath. It was a pleasure taking care of you! -Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "K219", "Z87891" ]
[ "I5031: Acute diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "D89813: Graft-versus-host disease, unspecified", "T865: Complications of stem cell transplant", "D46Z: Other myelodysplastic syndromes", "D801: Nonfamilial hypogammaglobulinemia", "I481: Persistent atrial fibrillation", "R000: Tachycardia, unspecified", "Z7952: Long term (current) use of systemic steroids", "Z7982: Long term (current) use of aspirin", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "Z85828: Personal history of other malignant neoplasm of skin", "Z8701: Personal history of pneumonia (recurrent)", "G4730: Sleep apnea, unspecified", "Z803: Family history of malignant neoplasm of breast", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung" ]
10,064,049
22,275,203
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with hx of MDS, ___ allogeneic stem cell transplant in ___, on IVIG, h/o Afib, CHF who presents with weakness and lightheadedness. Pt notes about a week ago he had a fall with headstrike. Denies syncope or LOC but states he tripped on a curb. He went to ___ where he reports having a normal head CT. Over the past week he has noted feeling more weak and fatigued. He also notes an increase in usual diarrhea to up to 3 BM per today. His torsemide and rate control agents have been recently modified multiple times. In brief, he was initially changed from Lasix 60 mg daily to torsemide 20 mg daily. He then lost ___ lbs quickly with symptomatic hypotension. His diuretic was subsequently held and his metop and dilt decreased to q8h from q6h with improvement in BP. He regained about 7 lbs (179 to 186 lbs) off diuretics. He was then seen on ___ by ___ NP service in the office and was noted to be volume overloaded. He was restarted on torsemide 10 mg daily and increased metoprolol and diltiazem to q6h from q8h. However, on ___, his weight decreased 186 lbs down to 177 lbs in 3 days and so torsemide was held. He also notes that he ran out of his metop and dilt earlier in week so did not take for several days. Today, pt was at heme/onc visit for IVIg (did not receive). He reported feeling unwell, lightheaded and weak. His HR was in 140s with BP 80/50 and so was sent to ED for further management. In the ED initial vitals were: T 97.3 HR 125 BP 98/62 RR 18 100% RA EKG: coarse afib, ventricular rate 98, left axis deviation. Labs/studies notable for: WBC 1, H/H 7.6/22.9, platelet count of 25, Creatinine 2.5 (bl cr 1.1-2.1). K+ 3.0. Imaging notable for CXR with No acute cardiopulmonary process Patient was given: 40 mg po K+, home metop tartate 50 mg x2, home diltiazem 60 mg po, and 250 ccs NS On the floor, pt states he feels improved. Denies any CP or SOB. ROS: On review of systems, + worsening diarrhea, chronic nonproductive cough, occasional dysuria Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: - ___: C1 Decitabine - ___: C2 Decitabine - ___: C3 Decitabine - ___: C4 Decitabine - ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor ***Peripheral engraftment ___: 99% donor ***Peripheral engraftment ___: 100% donor ***Peripheral engraftment ___: 100% donor ***Bone arrow engraftment ___: 100% donor ***Peripheral blood engraftment ___: 100% donor ***Peripheral blood engraftment (cytogenetics done at ___, ___: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --___: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --___: Changed to CTX/minocycline --___: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - ___: C1: IVIG - ___: C2: IVIG - ___: C3: IVIG - ___: C4 IVIG - ___: IVIG ***Voriconazole stopped on ___ ***Posaconazole started on ___, on hold since ___ PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD ___ EGD - ___ inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.9, 90/62, HR 110s-130s, 100% on RA GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM CARDIAC: ___, tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: ___ ___ edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities DISCHARGE PHYSICAL EXAM: GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM, L subconjuctival hemorrhage improving CARDIAC: ___, tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ ___ pretibial edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities Pertinent Results: ADMISSION LABS: =============== ___ 10:55AM BLOOD WBC-1.0* RBC-2.52* Hgb-7.6* Hct-22.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-20.3* RDWSD-64.0* Plt Ct-15* ___ 10:55AM BLOOD Neuts-61 Bands-2 Lymphs-14* Monos-20* Eos-3 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-0.63* AbsLymp-0.14* AbsMono-0.20 AbsEos-0.03* AbsBaso-0.00* ___ 05:32AM BLOOD ___ PTT-25.2 ___ ___ 10:55AM BLOOD Ret Aut-0.9 Abs Ret-0.02 ___ 10:55AM BLOOD Glucose-130* UreaN-60* Creat-2.4* Na-138 K-3.0* Cl-105 HCO3-23 AnGap-13 ___ 10:55AM BLOOD ALT-79* AST-31 LD(LDH)-219 AlkPhos-541* TotBili-0.7 ___ 10:55AM BLOOD cTropnT-0.02* proBNP-5968* ___ 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:55AM BLOOD TotProt-4.7* Albumin-3.0* Globuln-1.7* Calcium-8.3* Phos-4.8* Mg-1.6 UricAcd-13.7* ___ 10:55AM BLOOD Hapto-250* ___ 01:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:15PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 ___ 01:15PM URINE CastHy-7* ___ 01:15PM URINE Mucous-RARE OTHER PERTINENT/DISCHARGE LABS: =============== ___ 11:32AM URINE Hours-RANDOM UreaN-845 Creat-72 Na-57 K-35 Cl-48 ___ 06:10AM BLOOD WBC-1.2* RBC-2.60* Hgb-8.1* Hct-23.8* MCV-92 MCH-31.2 MCHC-34.0 RDW-19.0* RDWSD-58.9* Plt Ct-38* ___ 06:00AM BLOOD WBC-1.2* RBC-2.39* Hgb-7.2* Hct-21.9* MCV-92 MCH-30.1 MCHC-32.9 RDW-19.8* RDWSD-62.4* Plt Ct-13* ___ 06:10AM BLOOD Plt Ct-38* ___ 05:00PM BLOOD Plt Ct-54*# ___ 06:00AM BLOOD Plt Ct-13* ___ 05:32AM BLOOD ___ PTT-25.2 ___ ___ 12:58PM BLOOD Glucose-137* UreaN-26* Creat-1.3* Na-141 K-3.7 Cl-110* HCO3-23 AnGap-12 ___ 06:10AM BLOOD ALT-71* AST-43* LD(LDH)-233 AlkPhos-608* TotBili-0.6 ___ 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:55AM BLOOD cTropnT-0.02* proBNP-5968* ___ 12:58PM BLOOD Calcium-8.1* Phos-2.2* Mg-2.5 ___ 10:55AM BLOOD Hapto-250* ___ 05:32AM BLOOD Digoxin-1.1 ___ 11:32AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:32AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 11:32AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 11:32AM URINE CastHy-1* ___ 11:32AM URINE Mucous-RARE IMAGING: =============== ___ CXR Right lower lobe pulmonary nodule was better assessed on prior CT. No new focal consolidation seen. MICROBIOLOGY: =============== ___ - blood culture x1 - pending ___ - urine culture - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ - stool c diff PCR - negative Brief Hospital Course: ___ yo M h/o MDS ___ alloSCT ___, h/o Afib, HFpEF who presents with fatigue, found to be in Afib with RVR and hypotensive. #Afib with RVR: etiology either medication noncompliance or changes in medication. No evidence of infection. Loaded with digoxin when first admitted as he was hypotensive and unable to tolerate home metoprolol or diltiazem. He eventually tolerated metoprolol and diltiazem and was discharged with heart rates in the 80-90s. He is not anticoagulated for a-fib due to thrombocytopenia (platelets 15) #Hypotension: Patient typically runs in systolic BP of ___. Continued home fludrocortisone in addition to treatment of afib as above. #HFrEF: patient with history of HF, has preserved EF on most recent TTE in ___ have a component of diastolic HF, which was unable to be assessed on most recent TTE. Multiple recent changes in outpatient diuretic regimen. He appeared volume overloaded on admission and was restarted on diuresis with torsemide when blood pressures and heart rates were better controlled. Patient instructed to call Cardiology office with weight fluctuations of 3lbs or more for instructions on adjusting outpatient diuretic regimen. ___: Bl creatinine 1.1, recently elevated in the last few weeks, now at 2.4. Likely secondary to cardiorenal etiology given poor forward flow vs prerenal given intermittently overdiuresed over this time period as well as well as worsening diarrhea. Improved quickly with rate control and holding diuresis. Stable with resumption of diuresis. #Diarrhea: chronic, due to graft vs host disease (GVHD). Negative c diff and negative recent adenovirus and CMV viral loads. #Nocardia - recent chest CT on ___ showing slowly involuting RLL nodule due to nocardia. Continued on clarithromycin. Discontinued Bactrim and started minocycline on ID recommendations per below. #MDS ___ alloSCT - continued on prophylactic posaconazole (hx of aspergillosis), prophylactic acyclovir, ursodiol, prednisone 5mg - pt evaluated by inpatient hem/onc at request of outpatient oncologist who recommended against IVIG administration while inpatient. Felt pancytopenia may be due to sulfa drugs (Bactrim) and recommended discussing with infectious disease about alternative treatment regiments for Nocardia. Inpatient infectious disease team was consulted on the request of outpatient ID physician. Team recommended d/c Bactrim and starting minocycline. Arranged for interval outpatient LFTs and outpatient ID follow-up #Pancytopenia -per hem/onc, likely medication side effect rather than graft failure. -per hem/onc, pt received 1U pRBC and 1U platelets with appropriate rise. Transfused with 20g IVIG prior to discharge as he missed usual dose due to hospitalization. Hem/Onc team to arrange outpatient follow-up -no DVT prophylaxis given thrombocytopenia -monitored daily CBC for transfusion needs TRANSITIONAL ISSUES: - -Full code -HCP: ___ (wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. FoLIC Acid 5 mg PO DAILY 3. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. PredniSONE 5 mg PO DAILY 7. Simethicone 80 mg PO QID:PRN gas and bloating 8. Ursodiol 300 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Diltiazem 60 mg PO Q6H 11. Metoprolol Tartrate 50 mg PO Q6H 12. Posaconazole Delayed Release Tablet 300 mg PO DAILY 13. Acyclovir 400 mg PO Q8H 14. Sulfameth/Trimethoprim SS 1 TAB PO BID 15. Clarithromycin 500 mg PO Q12H 16. Docusate Sodium 100 mg PO BID 17. Fludrocortisone Acetate 0.1 mg PO DAILY 18. Fluticasone Propionate NASAL 1 SPRY NU BID 19. Guaifenesin 10 mL PO Q6H:PRN cough 20. Psyllium Powder 1 PKT PO DAILY:PRN constipation 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. FoLIC Acid 5 mg PO DAILY 7. Guaifenesin 10 mL PO Q6H:PRN cough 8. Multivitamins 1 TAB PO DAILY 9. Posaconazole Delayed Release Tablet 300 mg PO DAILY 10. PredniSONE 5 mg PO DAILY 11. Simethicone 80 mg PO QID:PRN gas and bloating 12. Ursodiol 300 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 15. Psyllium Powder 1 PKT PO DAILY:PRN constipation 16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 17. Diltiazem 60 mg PO TID RX *diltiazem HCl 60 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 18. Clarithromycin 500 mg PO Q12H 19. Pantoprazole 40 mg PO Q24H 20. Metoprolol Succinate XL 150 mg PO BID RX *metoprolol succinate 50 mg 3 tablet(s) by mouth twice daily Disp #*180 Tablet Refills:*0 21. Minocycline 100 mg PO BID You will need liver tests to ensure they are stable. RX *minocycline 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*0 22. Outpatient Lab Work Liver function tests (LFTS) On ___. ICD-10 J18.9. Send results to Dr ___ fax ___, tel ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: atrial fibrillation with rapid ventricular response acute kidney injury Secondary: heart failure with reduced ejection fraction Myelodysplastic Syndrome with Refractory Anemia with Excess Blasts Type II 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 caring for you at ___ ___. You were admitted with fast heart rate, known as atrial fibrillation with rapid ventricular response. While you were here, we gave you medications to control your heart rate. Additionally, we gave you diuretics, which are medications to help you urinate. At discharge, you weighed 78.6kg (173lbs). It is very important that you weigh yourself every morning before getting dressed and after going to the bathroom. Call your doctors if your ___ goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days. Please STOP taking Bactrim and start taking minocycline. You will need to follow up with Dr. ___ to discuss further treamtents for your Nocardia infection. We wish you all the best, Your ___ Cardiology team Followup Instructions: ___
[ "I480", "D61811", "N179", "D89813", "T865", "I959", "D4622", "A430", "I5032", "R197", "Y830", "I10", "Z85828", "K219", "Z87891", "T50905A", "Y929", "E876", "Z7952" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: weakness, lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] year old male with hx of MDS, [MASKED] allogeneic stem cell transplant in [MASKED], on IVIG, h/o Afib, CHF who presents with weakness and lightheadedness. Pt notes about a week ago he had a fall with headstrike. Denies syncope or LOC but states he tripped on a curb. He went to [MASKED] where he reports having a normal head CT. Over the past week he has noted feeling more weak and fatigued. He also notes an increase in usual diarrhea to up to 3 BM per today. His torsemide and rate control agents have been recently modified multiple times. In brief, he was initially changed from Lasix 60 mg daily to torsemide 20 mg daily. He then lost [MASKED] lbs quickly with symptomatic hypotension. His diuretic was subsequently held and his metop and dilt decreased to q8h from q6h with improvement in BP. He regained about 7 lbs (179 to 186 lbs) off diuretics. He was then seen on [MASKED] by [MASKED] NP service in the office and was noted to be volume overloaded. He was restarted on torsemide 10 mg daily and increased metoprolol and diltiazem to q6h from q8h. However, on [MASKED], his weight decreased 186 lbs down to 177 lbs in 3 days and so torsemide was held. He also notes that he ran out of his metop and dilt earlier in week so did not take for several days. Today, pt was at heme/onc visit for IVIg (did not receive). He reported feeling unwell, lightheaded and weak. His HR was in 140s with BP 80/50 and so was sent to ED for further management. In the ED initial vitals were: T 97.3 HR 125 BP 98/62 RR 18 100% RA EKG: coarse afib, ventricular rate 98, left axis deviation. Labs/studies notable for: WBC 1, H/H 7.6/22.9, platelet count of 25, Creatinine 2.5 (bl cr 1.1-2.1). K+ 3.0. Imaging notable for CXR with No acute cardiopulmonary process Patient was given: 40 mg po K+, home metop tartate 50 mg x2, home diltiazem 60 mg po, and 250 ccs NS On the floor, pt states he feels improved. Denies any CP or SOB. ROS: On review of systems, + worsening diarrhea, chronic nonproductive cough, occasional dysuria Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seen in MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: - [MASKED]: C1 Decitabine - [MASKED]: C2 Decitabine - [MASKED]: C3 Decitabine - [MASKED]: C4 Decitabine - [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor ***Peripheral engraftment [MASKED]: 99% donor ***Peripheral engraftment [MASKED]: 100% donor ***Peripheral engraftment [MASKED]: 100% donor ***Bone arrow engraftment [MASKED]: 100% donor ***Peripheral blood engraftment [MASKED]: 100% donor ***Peripheral blood engraftment (cytogenetics done at [MASKED], [MASKED]: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment [MASKED]: 100% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL --[MASKED]: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --[MASKED]: Started on posaconazole for fungal prophylaxis --[MASKED]: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --[MASKED]: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --[MASKED]: Changed to CTX/minocycline --[MASKED]: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - [MASKED]: C1: IVIG - [MASKED]: C2: IVIG - [MASKED]: C3: IVIG - [MASKED]: C4 IVIG - [MASKED]: IVIG ***Voriconazole stopped on [MASKED] ***Posaconazole started on [MASKED], on hold since [MASKED] PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD [MASKED] EGD - [MASKED] inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.9, 90/62, HR 110s-130s, 100% on RA GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM CARDIAC: [MASKED], tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: [MASKED] [MASKED] edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities DISCHARGE PHYSICAL EXAM: GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM, L subconjuctival hemorrhage improving CARDIAC: [MASKED], tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ [MASKED] pretibial edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:55AM BLOOD WBC-1.0* RBC-2.52* Hgb-7.6* Hct-22.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-20.3* RDWSD-64.0* Plt Ct-15* [MASKED] 10:55AM BLOOD Neuts-61 Bands-2 Lymphs-14* Monos-20* Eos-3 Baso-0 [MASKED] Myelos-0 NRBC-1* AbsNeut-0.63* AbsLymp-0.14* AbsMono-0.20 AbsEos-0.03* AbsBaso-0.00* [MASKED] 05:32AM BLOOD [MASKED] PTT-25.2 [MASKED] [MASKED] 10:55AM BLOOD Ret Aut-0.9 Abs Ret-0.02 [MASKED] 10:55AM BLOOD Glucose-130* UreaN-60* Creat-2.4* Na-138 K-3.0* Cl-105 HCO3-23 AnGap-13 [MASKED] 10:55AM BLOOD ALT-79* AST-31 LD(LDH)-219 AlkPhos-541* TotBili-0.7 [MASKED] 10:55AM BLOOD cTropnT-0.02* proBNP-5968* [MASKED] 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 10:55AM BLOOD TotProt-4.7* Albumin-3.0* Globuln-1.7* Calcium-8.3* Phos-4.8* Mg-1.6 UricAcd-13.7* [MASKED] 10:55AM BLOOD Hapto-250* [MASKED] 01:15PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 01:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 01:15PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 01:15PM URINE CastHy-7* [MASKED] 01:15PM URINE Mucous-RARE OTHER PERTINENT/DISCHARGE LABS: =============== [MASKED] 11:32AM URINE Hours-RANDOM UreaN-845 Creat-72 Na-57 K-35 Cl-48 [MASKED] 06:10AM BLOOD WBC-1.2* RBC-2.60* Hgb-8.1* Hct-23.8* MCV-92 MCH-31.2 MCHC-34.0 RDW-19.0* RDWSD-58.9* Plt Ct-38* [MASKED] 06:00AM BLOOD WBC-1.2* RBC-2.39* Hgb-7.2* Hct-21.9* MCV-92 MCH-30.1 MCHC-32.9 RDW-19.8* RDWSD-62.4* Plt Ct-13* [MASKED] 06:10AM BLOOD Plt Ct-38* [MASKED] 05:00PM BLOOD Plt Ct-54*# [MASKED] 06:00AM BLOOD Plt Ct-13* [MASKED] 05:32AM BLOOD [MASKED] PTT-25.2 [MASKED] [MASKED] 12:58PM BLOOD Glucose-137* UreaN-26* Creat-1.3* Na-141 K-3.7 Cl-110* HCO3-23 AnGap-12 [MASKED] 06:10AM BLOOD ALT-71* AST-43* LD(LDH)-233 AlkPhos-608* TotBili-0.6 [MASKED] 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 10:55AM BLOOD cTropnT-0.02* proBNP-5968* [MASKED] 12:58PM BLOOD Calcium-8.1* Phos-2.2* Mg-2.5 [MASKED] 10:55AM BLOOD Hapto-250* [MASKED] 05:32AM BLOOD Digoxin-1.1 [MASKED] 11:32AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 11:32AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 11:32AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 11:32AM URINE CastHy-1* [MASKED] 11:32AM URINE Mucous-RARE IMAGING: =============== [MASKED] CXR Right lower lobe pulmonary nodule was better assessed on prior CT. No new focal consolidation seen. MICROBIOLOGY: =============== [MASKED] - blood culture x1 - pending [MASKED] - urine culture - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] - stool c diff PCR - negative Brief Hospital Course: [MASKED] yo M h/o MDS [MASKED] alloSCT [MASKED], h/o Afib, HFpEF who presents with fatigue, found to be in Afib with RVR and hypotensive. #Afib with RVR: etiology either medication noncompliance or changes in medication. No evidence of infection. Loaded with digoxin when first admitted as he was hypotensive and unable to tolerate home metoprolol or diltiazem. He eventually tolerated metoprolol and diltiazem and was discharged with heart rates in the 80-90s. He is not anticoagulated for a-fib due to thrombocytopenia (platelets 15) #Hypotension: Patient typically runs in systolic BP of [MASKED]. Continued home fludrocortisone in addition to treatment of afib as above. #HFrEF: patient with history of HF, has preserved EF on most recent TTE in [MASKED] have a component of diastolic HF, which was unable to be assessed on most recent TTE. Multiple recent changes in outpatient diuretic regimen. He appeared volume overloaded on admission and was restarted on diuresis with torsemide when blood pressures and heart rates were better controlled. Patient instructed to call Cardiology office with weight fluctuations of 3lbs or more for instructions on adjusting outpatient diuretic regimen. [MASKED]: Bl creatinine 1.1, recently elevated in the last few weeks, now at 2.4. Likely secondary to cardiorenal etiology given poor forward flow vs prerenal given intermittently overdiuresed over this time period as well as well as worsening diarrhea. Improved quickly with rate control and holding diuresis. Stable with resumption of diuresis. #Diarrhea: chronic, due to graft vs host disease (GVHD). Negative c diff and negative recent adenovirus and CMV viral loads. #Nocardia - recent chest CT on [MASKED] showing slowly involuting RLL nodule due to nocardia. Continued on clarithromycin. Discontinued Bactrim and started minocycline on ID recommendations per below. #MDS [MASKED] alloSCT - continued on prophylactic posaconazole (hx of aspergillosis), prophylactic acyclovir, ursodiol, prednisone 5mg - pt evaluated by inpatient hem/onc at request of outpatient oncologist who recommended against IVIG administration while inpatient. Felt pancytopenia may be due to sulfa drugs (Bactrim) and recommended discussing with infectious disease about alternative treatment regiments for Nocardia. Inpatient infectious disease team was consulted on the request of outpatient ID physician. Team recommended d/c Bactrim and starting minocycline. Arranged for interval outpatient LFTs and outpatient ID follow-up #Pancytopenia -per hem/onc, likely medication side effect rather than graft failure. -per hem/onc, pt received 1U pRBC and 1U platelets with appropriate rise. Transfused with 20g IVIG prior to discharge as he missed usual dose due to hospitalization. Hem/Onc team to arrange outpatient follow-up -no DVT prophylaxis given thrombocytopenia -monitored daily CBC for transfusion needs TRANSITIONAL ISSUES: - -Full code -HCP: [MASKED] (wife, [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. FoLIC Acid 5 mg PO DAILY 3. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. PredniSONE 5 mg PO DAILY 7. Simethicone 80 mg PO QID:PRN gas and bloating 8. Ursodiol 300 mg PO BID 9. Vitamin D [MASKED] UNIT PO DAILY 10. Diltiazem 60 mg PO Q6H 11. Metoprolol Tartrate 50 mg PO Q6H 12. Posaconazole Delayed Release Tablet 300 mg PO DAILY 13. Acyclovir 400 mg PO Q8H 14. Sulfameth/Trimethoprim SS 1 TAB PO BID 15. Clarithromycin 500 mg PO Q12H 16. Docusate Sodium 100 mg PO BID 17. Fludrocortisone Acetate 0.1 mg PO DAILY 18. Fluticasone Propionate NASAL 1 SPRY NU BID 19. Guaifenesin 10 mL PO Q6H:PRN cough 20. Psyllium Powder 1 PKT PO DAILY:PRN constipation 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. FoLIC Acid 5 mg PO DAILY 7. Guaifenesin 10 mL PO Q6H:PRN cough 8. Multivitamins 1 TAB PO DAILY 9. Posaconazole Delayed Release Tablet 300 mg PO DAILY 10. PredniSONE 5 mg PO DAILY 11. Simethicone 80 mg PO QID:PRN gas and bloating 12. Ursodiol 300 mg PO BID 13. Vitamin D [MASKED] UNIT PO DAILY 14. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 15. Psyllium Powder 1 PKT PO DAILY:PRN constipation 16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 17. Diltiazem 60 mg PO TID RX *diltiazem HCl 60 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 18. Clarithromycin 500 mg PO Q12H 19. Pantoprazole 40 mg PO Q24H 20. Metoprolol Succinate XL 150 mg PO BID RX *metoprolol succinate 50 mg 3 tablet(s) by mouth twice daily Disp #*180 Tablet Refills:*0 21. Minocycline 100 mg PO BID You will need liver tests to ensure they are stable. RX *minocycline 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*0 22. Outpatient Lab Work Liver function tests (LFTS) On [MASKED]. ICD-10 J18.9. Send results to Dr [MASKED] fax [MASKED], tel [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: atrial fibrillation with rapid ventricular response acute kidney injury Secondary: heart failure with reduced ejection fraction Myelodysplastic Syndrome with Refractory Anemia with Excess Blasts Type II 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 caring for you at [MASKED] [MASKED]. You were admitted with fast heart rate, known as atrial fibrillation with rapid ventricular response. While you were here, we gave you medications to control your heart rate. Additionally, we gave you diuretics, which are medications to help you urinate. At discharge, you weighed 78.6kg (173lbs). It is very important that you weigh yourself every morning before getting dressed and after going to the bathroom. Call your doctors if your [MASKED] goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days. Please STOP taking Bactrim and start taking minocycline. You will need to follow up with Dr. [MASKED] to discuss further treamtents for your Nocardia infection. We wish you all the best, Your [MASKED] Cardiology team Followup Instructions: [MASKED]
[]
[ "I480", "N179", "I5032", "I10", "K219", "Z87891", "Y929" ]
[ "I480: Paroxysmal atrial fibrillation", "D61811: Other drug-induced pancytopenia", "N179: Acute kidney failure, unspecified", "D89813: Graft-versus-host disease, unspecified", "T865: Complications of stem cell transplant", "I959: Hypotension, unspecified", "D4622: Refractory anemia with excess of blasts 2", "A430: Pulmonary nocardiosis", "I5032: Chronic diastolic (congestive) heart failure", "R197: Diarrhea, 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", "I10: Essential (primary) hypertension", "Z85828: Personal history of other malignant neoplasm of skin", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "T50905A: Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter", "Y929: Unspecified place or not applicable", "E876: Hypokalemia", "Z7952: Long term (current) use of systemic steroids" ]
10,064,049
23,906,242
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ yr old male wth Hx of MDS, ___ allogeneic BMT ___, course complicated by GI GVH on CSA and prednisone recently weaning, hx afib RVR on digoxin and recent admission for this during which he required significant diuresis. Pt referred in to ED ___ with acute onset loose stools ___ now watery diarrhea, nearly every hour. Endorses soreness in rectum with passing BM, feels like his known hemorrhoid pain. Denies fever or chills. Denies BRBPR or melena. Denies nausea/vomiting. Ate a sandwich earlier in day prior to coming in. No new rash or eye changes. States that his leg swelling is signficantly improved and continued to lose at least 10lb from discharge with ongoing diuresis. Feels that this was rapid and really wiped him out. Endorses new dysuria but on arrival to floor no longer noticing this, no hematuria. Denies cough, has ongoing DOE for instance has to go up stairs very slowly but overall felt he was starting to recover from last hospitalization until he developed this diarrhea. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: ___: C1 Decitabine ___: C2 Decitabine ___: C3 Decitabine ___: C4 Decitabine ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor ***Peripheral engraftment ___: 99% donor ***Peripheral engraftment ___: 100% donor ***Peripheral engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem-->cefepime-->completing a 2 week course of outpatient cipro ADDITIONAL TREATMENT: ___: C1: IVIG ___: C2: IVIG ___: C3: IVIG ___: C4 IVIG ***Voriconazole stopped on ___ ***Posaconazole started on ___ PAST MEDICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD ___ EGD -___ inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: GEN: NAD VITAL SIGNS: 97.8 117/55 61 18 98%RA HEENT: MMM, no OP lesions or thrush CV: Irregularly irregular, normal rate, NL S1S2 no S3S4 MRG PULM: CTAB nonlabored ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, Romberg is non pathologic, coordination is intact. DISCHARGE PHYSICAL EXAM: GEN: NAD VITAL SIGNS: 98.2 ___ 18 97%RA HEENT: MMM, no OP lesions or thrush CV: Irregularly irregular, normal rate, NL S1S2 no S3S4 MRG PULM: CTAB non-labored ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Grossly non-focal. A/O x 3 Pertinent Results: Admission Labs ___ 10:25PM BLOOD WBC-8.4 RBC-2.26* Hgb-9.0* Hct-26.3* MCV-116* MCH-39.8* MCHC-34.2 RDW-18.7* RDWSD-77.4* Plt Ct-93* ___ 10:25PM BLOOD Neuts-88* Bands-0 Lymphs-2* Monos-6 Eos-0 Baso-1 ___ Metas-1* Myelos-2* AbsNeut-7.39* AbsLymp-0.17* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.08 ___ 10:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL ___ 10:25PM BLOOD Plt Smr-LOW Plt Ct-93* ___ 10:25PM BLOOD Glucose-142* UreaN-50* Creat-1.7* Na-130* K-5.1 Cl-92* HCO3-25 AnGap-18 ___ 06:26AM BLOOD ALT-34 AST-38 LD(LDH)-445* AlkPhos-101 TotBili-0.6 ___ 10:25PM BLOOD ___ ___ 06:26AM BLOOD Cyclspr-287 ___ 10:32PM BLOOD Lactate-2.5* Discharge Labs ___ 11:30AM BLOOD WBC-6.5 RBC-1.99* Hgb-8.0* Hct-23.5* MCV-118* MCH-40.2* MCHC-34.0 RDW-19.1* RDWSD-81.3* Plt Ct-77* ___ 11:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Stipple-OCCASIONAL Tear Dr-OCCASIONAL ___ 11:30AM BLOOD Plt Smr-VERY LOW Plt Ct-77* ___ 11:30AM BLOOD Glucose-138* UreaN-35* Creat-1.3* Na-133 K-3.7 Cl-97 HCO3-26 AnGap-14 ___ 11:30AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.0 Mg-2.1 Brief Hospital Course: Mr. ___ is a ___ year old male with hx of MDS ___ allogenic stem cell transplant D+303 c/b GI GVHD (on cyclosporine and pred) who presents with diarrhea which has since resolved. #Acute diarrhea - Appears euvolemic and has improved after IVFs. He has had no diarrhea since admission. This is unlikely to be GVHD and more likely to be gastroenteritis. He is improving clinically. - bland diet, encourage increase oral liquid intake - IVF hydration - C diff neg, other stool cultures pending - CMV VL ___ undetect ___: Cr on admission 1.7, improved with IVFs now are baseline. Cr 1.3 today - patient drank about 1.5L today prior to discharge. His baseline weight is 180s and he is currently 176. -trending lytes #MDS RAEB TYPE II day +303 post allo HSCT: engrafted, 100% donor chimerism, no signs recurrence. - ppx: continue atovaquone, acyclovir, ursodiol and posaconazole (hx aspergillosis) #HX GI GVHD: -CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H -Cyclosporine 0.05% Ophth Emulsion 2 DROP BOTH EYES Q12H -PredniSONE 15 mg PO/NG DAILY #Afib: continue metoprolol, dig, dilitiazem #dCHF: No signs of decompensation. He is below his dry weight currently, cont metop FEN: - Electrolytes per oncology scales - Regular diet, bland BOWEL REGIMEN: held all stool softeners due to diarrhea DVT PROPHYLAXIS: - Heparin 5000 units SC BID ACCESS: - PIV CODE STATUS: - Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Atovaquone Suspension 1500 mg PO DAILY 4. Budesonide 3 mg PO TID 5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 6. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 7. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 8. Diltiazem Extended-Release 240 mg PO DAILY 9. FoLIC Acid 5 mg PO DAILY 10. Magnesium Oxide 400 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. PredniSONE 15 mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Pantoprazole 40 mg PO Q12H 16. Posaconazole Delayed Release Tablet 300 mg PO DAILY 17. Simethicone 40-80 mg PO QID:PRN gas/bloating 18. Ursodiol 300 mg PO BID 19. Digoxin 0.125 mg PO DAILY Afib 20. Oxymetazoline 1 SPRY NU BID:PRN Congestion 21. copper gluconate 2 mg oral DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Budesonide 3 mg PO TID 3. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. PredniSONE 15 mg PO DAILY 7. Vitamin D ___ UNIT PO DAILY 8. Ursodiol 300 mg PO BID 9. Simethicone 40-80 mg PO QID:PRN gas/bloating 10. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 11. Atovaquone Suspension 1500 mg PO DAILY 12. copper gluconate 2 mg oral DAILY 13. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 14. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 15. Digoxin 0.125 mg PO DAILY Afib 16. FoLIC Acid 5 mg PO DAILY 17. Metoprolol Succinate XL 50 mg PO DAILY 18. Pantoprazole 40 mg PO Q12H 19. Posaconazole Delayed Release Tablet 300 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Oxymetazoline 1 SPRY NU BID:PRN Congestion Discharge Disposition: Home Discharge Diagnosis: Primary: ___, diarrhea, MDS, Graft versus Host Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for diarrhea which resolved. We think that the likely cause is gastroenteritis. You also had mild kidney injury which also resolved and was likely because you were dehydrated. Please continue to drink fluids to ensure your kidneys are not aggravated. It was a pleasure taking care of you. Please do not hesitate to contact us if you have any concerns or questions about care. Your follow up appointments are listed below. Followup Instructions: ___
[ "N179", "D89813", "R197", "D4622", "I4891", "R300", "I10", "G4730", "Z85828", "K219", "Z87891", "I5032", "M109", "K649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr [MASKED] is a [MASKED] yr old male wth Hx of MDS, [MASKED] allogeneic BMT [MASKED], course complicated by GI GVH on CSA and prednisone recently weaning, hx afib RVR on digoxin and recent admission for this during which he required significant diuresis. Pt referred in to ED [MASKED] with acute onset loose stools [MASKED] now watery diarrhea, nearly every hour. Endorses soreness in rectum with passing BM, feels like his known hemorrhoid pain. Denies fever or chills. Denies BRBPR or melena. Denies nausea/vomiting. Ate a sandwich earlier in day prior to coming in. No new rash or eye changes. States that his leg swelling is signficantly improved and continued to lose at least 10lb from discharge with ongoing diuresis. Feels that this was rapid and really wiped him out. Endorses new dysuria but on arrival to floor no longer noticing this, no hematuria. Denies cough, has ongoing DOE for instance has to go up stairs very slowly but overall felt he was starting to recover from last hospitalization until he developed this diarrhea. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seen in MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: [MASKED]: C1 Decitabine [MASKED]: C2 Decitabine [MASKED]: C3 Decitabine [MASKED]: C4 Decitabine [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor ***Peripheral engraftment [MASKED]: 99% donor ***Peripheral engraftment [MASKED]: 100% donor ***Peripheral engraftment [MASKED]: 100% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL --[MASKED]: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --[MASKED]: Started on posaconazole for fungal prophylaxis --[MASKED]: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem-->cefepime-->completing a 2 week course of outpatient cipro ADDITIONAL TREATMENT: [MASKED]: C1: IVIG [MASKED]: C2: IVIG [MASKED]: C3: IVIG [MASKED]: C4 IVIG ***Voriconazole stopped on [MASKED] ***Posaconazole started on [MASKED] PAST MEDICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD [MASKED] EGD -[MASKED] inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: GEN: NAD VITAL SIGNS: 97.8 117/55 61 18 98%RA HEENT: MMM, no OP lesions or thrush CV: Irregularly irregular, normal rate, NL S1S2 no S3S4 MRG PULM: CTAB nonlabored ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is [MASKED] of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, Romberg is non pathologic, coordination is intact. DISCHARGE PHYSICAL EXAM: GEN: NAD VITAL SIGNS: 98.2 [MASKED] 18 97%RA HEENT: MMM, no OP lesions or thrush CV: Irregularly irregular, normal rate, NL S1S2 no S3S4 MRG PULM: CTAB non-labored ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Grossly non-focal. A/O x 3 Pertinent Results: Admission Labs [MASKED] 10:25PM BLOOD WBC-8.4 RBC-2.26* Hgb-9.0* Hct-26.3* MCV-116* MCH-39.8* MCHC-34.2 RDW-18.7* RDWSD-77.4* Plt Ct-93* [MASKED] 10:25PM BLOOD Neuts-88* Bands-0 Lymphs-2* Monos-6 Eos-0 Baso-1 [MASKED] Metas-1* Myelos-2* AbsNeut-7.39* AbsLymp-0.17* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.08 [MASKED] 10:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL [MASKED] 10:25PM BLOOD Plt Smr-LOW Plt Ct-93* [MASKED] 10:25PM BLOOD Glucose-142* UreaN-50* Creat-1.7* Na-130* K-5.1 Cl-92* HCO3-25 AnGap-18 [MASKED] 06:26AM BLOOD ALT-34 AST-38 LD(LDH)-445* AlkPhos-101 TotBili-0.6 [MASKED] 10:25PM BLOOD [MASKED] [MASKED] 06:26AM BLOOD Cyclspr-287 [MASKED] 10:32PM BLOOD Lactate-2.5* Discharge Labs [MASKED] 11:30AM BLOOD WBC-6.5 RBC-1.99* Hgb-8.0* Hct-23.5* MCV-118* MCH-40.2* MCHC-34.0 RDW-19.1* RDWSD-81.3* Plt Ct-77* [MASKED] 11:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Stipple-OCCASIONAL Tear Dr-OCCASIONAL [MASKED] 11:30AM BLOOD Plt Smr-VERY LOW Plt Ct-77* [MASKED] 11:30AM BLOOD Glucose-138* UreaN-35* Creat-1.3* Na-133 K-3.7 Cl-97 HCO3-26 AnGap-14 [MASKED] 11:30AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.0 Mg-2.1 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with hx of MDS [MASKED] allogenic stem cell transplant D+303 c/b GI GVHD (on cyclosporine and pred) who presents with diarrhea which has since resolved. #Acute diarrhea - Appears euvolemic and has improved after IVFs. He has had no diarrhea since admission. This is unlikely to be GVHD and more likely to be gastroenteritis. He is improving clinically. - bland diet, encourage increase oral liquid intake - IVF hydration - C diff neg, other stool cultures pending - CMV VL [MASKED] undetect [MASKED]: Cr on admission 1.7, improved with IVFs now are baseline. Cr 1.3 today - patient drank about 1.5L today prior to discharge. His baseline weight is 180s and he is currently 176. -trending lytes #MDS RAEB TYPE II day +303 post allo HSCT: engrafted, 100% donor chimerism, no signs recurrence. - ppx: continue atovaquone, acyclovir, ursodiol and posaconazole (hx aspergillosis) #HX GI GVHD: -CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H -Cyclosporine 0.05% Ophth Emulsion 2 DROP BOTH EYES Q12H -PredniSONE 15 mg PO/NG DAILY #Afib: continue metoprolol, dig, dilitiazem #dCHF: No signs of decompensation. He is below his dry weight currently, cont metop FEN: - Electrolytes per oncology scales - Regular diet, bland BOWEL REGIMEN: held all stool softeners due to diarrhea DVT PROPHYLAXIS: - Heparin 5000 units SC BID ACCESS: - PIV CODE STATUS: - Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Atovaquone Suspension 1500 mg PO DAILY 4. Budesonide 3 mg PO TID 5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 6. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 7. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 8. Diltiazem Extended-Release 240 mg PO DAILY 9. FoLIC Acid 5 mg PO DAILY 10. Magnesium Oxide 400 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. PredniSONE 15 mg PO DAILY 13. Vitamin D [MASKED] UNIT PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Pantoprazole 40 mg PO Q12H 16. Posaconazole Delayed Release Tablet 300 mg PO DAILY 17. Simethicone 40-80 mg PO QID:PRN gas/bloating 18. Ursodiol 300 mg PO BID 19. Digoxin 0.125 mg PO DAILY Afib 20. Oxymetazoline 1 SPRY NU BID:PRN Congestion 21. copper gluconate 2 mg oral DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Budesonide 3 mg PO TID 3. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. PredniSONE 15 mg PO DAILY 7. Vitamin D [MASKED] UNIT PO DAILY 8. Ursodiol 300 mg PO BID 9. Simethicone 40-80 mg PO QID:PRN gas/bloating 10. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 11. Atovaquone Suspension 1500 mg PO DAILY 12. copper gluconate 2 mg oral DAILY 13. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 14. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 15. Digoxin 0.125 mg PO DAILY Afib 16. FoLIC Acid 5 mg PO DAILY 17. Metoprolol Succinate XL 50 mg PO DAILY 18. Pantoprazole 40 mg PO Q12H 19. Posaconazole Delayed Release Tablet 300 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Oxymetazoline 1 SPRY NU BID:PRN Congestion Discharge Disposition: Home Discharge Diagnosis: Primary: [MASKED], diarrhea, MDS, Graft versus Host Disease 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 diarrhea which resolved. We think that the likely cause is gastroenteritis. You also had mild kidney injury which also resolved and was likely because you were dehydrated. Please continue to drink fluids to ensure your kidneys are not aggravated. It was a pleasure taking care of you. Please do not hesitate to contact us if you have any concerns or questions about care. Your follow up appointments are listed below. Followup Instructions: [MASKED]
[]
[ "N179", "I4891", "I10", "K219", "Z87891", "I5032", "M109" ]
[ "N179: Acute kidney failure, unspecified", "D89813: Graft-versus-host disease, unspecified", "R197: Diarrhea, unspecified", "D4622: Refractory anemia with excess of blasts 2", "I4891: Unspecified atrial fibrillation", "R300: Dysuria", "I10: Essential (primary) hypertension", "G4730: Sleep apnea, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "I5032: Chronic diastolic (congestive) heart failure", "M109: Gout, unspecified", "K649: Unspecified hemorrhoids" ]
10,064,049
24,829,092
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: minocycline Attending: ___. Chief Complaint: Rising LFTs Major Surgical or Invasive Procedure: ___ liver biopsy PICC line placement and removal History of Present Illness: Mr. ___ is a ___ year old gentleman with a history of MDS - Refractory Anemia with Excess Blasts Type ___ s/p reduced intensity MRD allogeneic SCT now D+405 who presents from clinic with rising LFTs and fever. Overall has been feeling very fatigued. Also endorses sx of urinary frequency for the last few weeks. Had fever yesterday and again in clinic. He has a complicated post-transplant history. He has had severe GVHD of the gut treated with prednisone and cyclosporine, currently maintained on 5mg prednisone daily and budesonide. He was diagnosed with aspergillus and stenotrophomonas pneumonia on BAL on ___ and treated with levofloxacin and voriconazole, and then on ___ was started on posaconizole for fungal prophylaxis. On ___ he was found to have citrobacter bacteremia from a suspected line infection and treated with meropenem, then cefepime, and finally ciprofloxacin for a 2 week course. On ___ he was admitted with afib with RVR and found to have Nocardia nova pneumonia of RLL diagnosed on lung biopsy and treated with imipenim and minocycline, which on ___ was switched to ceftriaxone/minocycline for dosing convenience when he was leaving rehab. On ___ minocycline and posaconazole were held due to elevated LFTs. He has been at ___ since his discharge on ___ with a planned discharge this week. He was seen in clinic today w/ elevated LFTs and fever and admitted for hepatology w/u. On the floor denies abd pain, fevers, chills. +urinary frequency and feeling very tired. Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: - ___: C1 Decitabine - ___: C2 Decitabine - ___: C3 Decitabine - ___: C4 Decitabine - ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor ***Peripheral engraftment ___: 99% donor ***Peripheral engraftment ___: 100% donor ***Peripheral engraftment ___: 100% donor ***Bone arrow engraftment ___: 100% donor ***Peripheral blood engraftment ___: 100% donor ***Peripheral blood engraftment (cytogenetics done at ___, ___: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --___: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --___: Changed to CTX/minocycline --___: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - ___: C1: IVIG - ___: C2: IVIG - ___: C3: IVIG - ___: C4 IVIG - ___: IVIG ***Voriconazole stopped on ___ ***Posaconazole started on ___, on hold since ___ PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD s/p EGD - s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION EXAM ============== Vitals: 99.5 145/86 77 19 100RA GENERAL: No acute distress, fatigued. HEENT: Mucous membranes moist. OP clear. No petechiae. CHEST: CTAB although poor respiratory effort. CARDIAC: Irregularly irregular, no murmurs ABDOMEN: Hypoactive bowel sounds, slightly distended, no hepatosplenomegaly appreciated. Nontender. EXTREMITIES: 1+ pitting edema bilaterally to shins SKIN: Warm and dry, skin is very fragile, senile purpura over hands and ecchymotic lesions over the chest, face and neck NEURO: Alert and oriented to person but not date, season, year or place. Poor attention. CN2-12 intact. Mild weakness in the left upper extremity. Weakness with dorsiflexion of right foot, otherwise lower extremity strength intact. LINES: PICC in place in the LUE DISCHARGE EXAM ============== Vitals: Tmax 99.0 BP 90-120/60-80s HR 70-90s RR ___ O2 95-98% on RA GENERAL: Chronically ill appearing, appears anxious and confused HEENT: Scleral icterus, right conjunctival hemorrhage. Mucous membranes dry. CHEST: CTAB, no w/r/c CARDIAC: Irregularly irregular, no murmurs ABDOMEN: Moderately tender to palpation diffusely but predominantly in epigastrium and periumbilical areas. + BS, no organomegaly, negative ___ sign. EXTREMITIES: trace edema LUE and BLE. Otherwise WWP SKIN: Diffusely jaundiced. Prior left leg gauze removed. Warm and dry, skin is very fragile, purpura and ecchymoses over most of body but predominantly at right elbow and over chest area. ACCESS: Two 20 gauge PIVs NEURO: Minimally responsive, agitated, not oriented. Pertinent Results: ADMISSION LABS ============== ___ 10:20AM BLOOD WBC-0.2* RBC-2.80* Hgb-8.9* Hct-25.5* MCV-91 MCH-31.8 MCHC-34.9 RDW-18.2* RDWSD-57.4* Plt Ct-8*# ___ 10:20AM BLOOD Neuts-3* Bands-0 Lymphs-81* Monos-15* Eos-0 Baso-1 ___ Myelos-0 NRBC-2* AbsNeut-0.01* AbsLymp-0.16* AbsMono-0.03* AbsEos-0.00* AbsBaso-0.00* ___ 10:20AM BLOOD ___ PTT-25.3 ___ ___ 10:20AM BLOOD Glucose-108* UreaN-31* Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-23 AnGap-16 ___ 10:20AM BLOOD ALT-150* AST-51* LD(___)-231 AlkPhos-1553* TotBili-3.7* ___ 10:20AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.4* UricAcd-6.1 ___ 10:20AM BLOOD Digoxin-2.2* PERTINENT LABS ============== ___ 10:20AM BLOOD ALT-150* AST-51* LD(___)-231 AlkPhos-1553* TotBili-3.7* ___ 07:20AM BLOOD ALT-119* AST-58* LD(___)-181 AlkPhos-885* TotBili-4.6* ___ 06:00AM BLOOD ALT-236* AST-124* LD(___)-219 AlkPhos-842* TotBili-6.7* ___ 05:50AM BLOOD ALT-306* AST-121* LD(___)-260* AlkPhos-826* TotBili-9.3* ___ 12:10AM BLOOD ALT-218* AST-64* AlkPhos-673* TotBili-9.2* ___ 12:00AM BLOOD ALT-186* AST-71* LD(___)-292* AlkPhos-687* TotBili-8.9* ___ 12:05AM BLOOD ALT-171* AST-79* LD(___)-296* AlkPhos-620* TotBili-8.6* ___ 12:00AM BLOOD ALT-154* AST-72* AlkPhos-588* TotBili-9.0* DirBili-6.4* IndBili-2.6 ___ 12:00AM BLOOD ALT-164* AST-86* LD(___)-303* CK(CPK)-13* AlkPhos-597* TotBili-11.2* ___ 04:55AM BLOOD ALT-204* AST-112* LD(___)-347* AlkPhos-541* TotBili-14.0* ___ 07:10AM BLOOD ALT-261* AST-142* LD(___)-390* AlkPhos-607* TotBili-17.1* ___ 01:30AM BLOOD calTIBC-178* ___ TRF-137* ___ 06:05AM BLOOD Hapto-117 ___ 08:28AM BLOOD Hapto-34 ___ 01:30AM BLOOD Triglyc-112 HDL-34 CHOL/HD-4.4 LDLcalc-92 ___ 04:14PM BLOOD Ammonia-21 ___ 01:30AM BLOOD HBsAg-Negative HBsAb-Positive HAV Ab-Positive* ___ 12:00AM BLOOD IgM HAV-Negative ___ 01:30AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 01:30AM BLOOD ___ ___ 02:20PM BLOOD IgG-745 DISCHARGE LABS ============== ___ 06:05AM BLOOD WBC-0.1* RBC-2.35* Hgb-6.9* Hct-18.9* MCV-80* MCH-29.4 MCHC-36.5 RDW-16.7* RDWSD-46.5* Plt Ct-41* ___ 06:05AM BLOOD ___ PTT-26.3 ___ ___ 06:05AM BLOOD Glucose-90 UreaN-31* Creat-1.1 Na-133 K-3.4 Cl-98 HCO3-25 AnGap-13 ___ 06:05AM BLOOD ALT-270* AST-145* LD(LDH)-365* AlkPhos-519* TotBili-15.2* ___ 06:05AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0 IMAGING ======= ___ CHEST (PORTABLE AP) IMPRESSION: Compared to chest radiographs ___. Mildly enlarged cardiac silhouette obscures the left lower lobe. Lateral view would be helpful in detection of basal pneumonia or small pleural effusions. Upper lungs clear. No pneumothorax. ___ LIVER OR GALLBLADDER US IMPRESSION: No evidence of biliary obstruction. Cholelithiasis. Gallbladder is not distended. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial abnormality, with no evidence of acute intracranial hemorrhage. 2. Paranasal sinus disease as described. ___ CT ABD & PELVIS W/O CON IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Small volume ascites. New subtle omental stranding and nodularity in the left upper quadrant is nonspecific and could represent an unusual appearance of ascitic fluid. Follow-up imaging is recommended if the patient develops left-sided pain. 3. Unchanged pulmonary nodules. ___ UNILAT UP EXT VEINS US IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. ___ MRCP (MR ___ IMPRESSION: The gallbladder is decompressed with gallstones. Eccentric 9 mm stone in the proximal cystic duct, currently non-obstructing stone as there is no upstream or gallbladder dilatation however this may be early or become obstructing given its size. No evidence of intra or extrahepatic biliary dilatation or obstruction. No common duct stones. Hepatic and splenic hemosiderosis. Small amount of fluid in the right upper quadrant and trace in the left lower quadrant. ___ Cardiovascular ECHO The left atrial volume index is normal. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is beat-to-beat variability in ejection fraction. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild to moderate (___) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate aortic regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of ___, the severity of aortic regurgitation is slightly increased and the severity of mitral regurgitation is slightly reduced. ___ CHEST (PA & LAT) IMPRESSION: In comparison with the study ___, there is little interval change. Small bilateral pleural effusions are again seen in a patient with enlargement of the cardiac silhouette, but no vascular congestion or acute focal pneumonia. ___ CHEST (PA & LAT) IMPRESSION: New small bilateral pleural effusions, right greater than left ___ UNILAT UP EXT VEINS US IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. ___ LIVER OR GALLBLADDER US IMPRESSION: Gallstones. The gallbladder wall is thickened and edematous which is likely due to third spacing. Normal hepatic parenchyma without evidence of hepatic abscess. ___ CT CHEST W/O CONTRAST IMPRESSION: 1. The previously seen right lower lobe nodule, reportedly due to Nocardia infection, has further decreased in size. New small opacity in the inferior right upper lobe (4:124) could be localized aspiration or early/resolving infection. 2. Small bilateral pleural effusions. 3. Other findings are similar to prior. ___ CT ABD & PELVIS W/O CON IMPRESSION: 1. Mild gallbladder wall edema and small amount of free fluid in the pelvis likely reflects third-spacing. Cholecystitis is unlikely since the gallbladder is collapsed however further evaluation with ultrasound could be performed. 2. No definite source for fever identified MICROBIOLOGY ============ **all results below negative unless specified** ___ Immunology (CMV) CMV Viral Load-FINAL NEGATIVE ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ Immunology (CMV) CMV Viral Load-FINAL NEGATIVE ___ STOOL C. difficile DNA amplification assay-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT ___ IMMUNOLOGY HBV Viral Load-FINAL INPATIENT ___ Immunology (CMV) NOT PROCESSED INPATIENT ___ STOOL VIRAL CULTURE-FINAL INPATIENT ___ STOOL C. difficile DNA amplification assay-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ TISSUE VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL INPATIENT ___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT ___ Immunology (CMV) NOT PROCESSED INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL {KLEBSIELLA OXYTOCA} INPATIENT ___ Immunology (CMV) CMV Viral Load-FINAL Brief Hospital Course: BRIEF SUMMARY ============= Mr. ___ was a ___ year old male with MDS who underwent an allogeneic bone marrow transplant in ___ which was complicated by graft failure as well as GVHD. He presented to us in early ___ after being found to have a fever and rising LFTs, and after liver biopsy was found to have evidence of severe GVHD of the liver. He was treated with high dose methylprednisolone and mycophenolate, however his LFTs continued to rise. He developed VRE bacteremia, which was treated with daptomycin then linezolid but developed significant hypotension with sitting up likely due to sepsis. Because of his overall condition, he opted to be made comfort care only and passed away with his family at his bedside. ACUTE ISSUES ============ #Comfort measures only: Given patient's continuing decline in physical and mental function, he met with palliative care and hospice to discuss going home with hospice. Due to the rapid pace of his decline, he was made CMO while inpatient and passed away with his family at the bedside. # Transaminitis : # GVHD of liver : Pt noted to have rising LFTs prior to admission, liver bx showed evidence of GVHD as well as moderate to severe iron deposition. Started on methylprednisolone IV with mild improvement in LFTs initially, however bilirubin began to increase again. MRCP notable for non-obstructing stone in cystic duct but decompressed gallbladder, RUQUS with no evidence of obstruction. A broad microbiologic workup was performed which was unrevealing. MMF was added to his immunosuppressive regimen with no improvement. Due to his overall condition, he was made CMO as above. # VRE bacteremia: # Febrile neutropenia: # Klebsiella Oxytoca UTI: Initially febrile with klebsiella UTI on admission, placed on imipenem to cover GNRs and nocardia. On ___, BCx positive for enterococcus. He was initially treated with vancomycin x1 day, however sensitivites revealed vancomycin resistance so he was switched to daptomycin 8mg/kg. No other blood cultures were positive, however he experienced episodes of hypotension as below so was switched to linezolid, cefepime, and Flagyl with the thought that he may have been septic. #Hypotension: Towards the end of his course, pt became hypotensive to ___ systolic with sitting up, with several episodes of near-syncope and one episode where he became transiently non-responsive. Potentially due to sepsis, however liver failure can also cause hypotension and he probably has an element of hypovolemia as well. No significant improvement with fluid boluses, however. #Epigastric/LUQ abdominal pain: Pt experienced new onset epigastric and LUQ abdominal pain several days into starting steroids, may be ___ gastritis vs ulceration. Patient was given an IV PPI BID and never had any evidence of GI bleeding. #Altered mental status: Waxing and waning mental status with evidence of asterixis, potentially secondary to liver failure. Because he was stooling frequently we did not initiate lactulose. Ammonia level of 24. # ___ on CKD: Patient with baseline Cr in the 1.3-1.5 range over prior 6 months, elevated in the setting of hypovolemia, improved with IVF. #Dyspnea on exertion: Improved with pRBC transfusion, likely ___ symptomatic anemia. BNP significantly elevated and patient had bilateral lower extremity edema, however CXR on ___ showed no e/o volume overload. TTE with preserved systolic and diastolic function. #Left arm swelling: Likely related to PICC placement. Doppler U/S no e/o DVT. # MDS with RAEB type ___ s/p allo SCT: D+540 on admission. Patient has pre-transplant 45X,-Y karyotype. Recent peripheral blood chimerism study (___) showed 5.5%X, 94.5%XY. C/b secondary graft failure. Required intermittent transfusions for both pRBCs and platelets throughout his course. His brother (donor) traveled from out of state for harvesting of CD34+ stem cells for a possible stem cell boost given his persistent graft failure, however due to his rising LFTs and poor condition a decision was made to defer a stem cell boost. # Afib with RVR: CHA2DS-VASc score = 1 (age > ___). In atrial fibrillation on telemetry since admission. No longer being anti-coagulated given thrombocytopenia. Experienced likely Afib with RVR with rates in the 150s and pressures in the ___ on ___, which resolved spontaneously without intervention. Initially increased metoprolol from 50mg q6h to 62.5 mg q6h, however became hypotensive and bradycardic to decreased back to 50mg. Digoxin held on ___ given an episode of bradycardia to the ___, patient eventually CMO so all medications discontinued. # hx norcardia PNA: Given steroid use, initially restarted minocycline and clarithromycin for prophylaxis. Due to his LFT rise, both of these drugs were discontinued and he was treated with imipenem at first then cefepime as detailed above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. FoLIC Acid 5 mg PO DAILY 6. Guaifenesin 10 mL PO Q6H:PRN cough 7. Multivitamins 1 TAB PO DAILY 8. Posaconazole Delayed Release Tablet 300 mg PO DAILY 9. PredniSONE 5 mg PO DAILY 10. Simethicone 80 mg PO QID:PRN gas and bloating 11. Ursodiol 300 mg PO BID 12. Vitamin D ___ UNIT PO DAILY 13. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 14. Psyllium Powder 1 PKT PO DAILY:PRN constipation 15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 16. Pantoprazole 40 mg PO Q24H 17. Metoprolol Succinate XL 150 mg PO BID 18. Atovaquone Suspension 1500 mg PO DAILY 19. Cetirizine 10 mg PO DAILY 20. Digoxin 0.125 mg PO DAILY 21. Diltiazem 60 mg PO TID 22. Filgrastim 480 mcg SC Q24H 23. Artificial Tears ___ DROP BOTH EYES PRN dry eye 24. Zinc Sulfate Dose is Unknown PO DAILY Discharge Disposition: Expired Discharge Diagnosis: -transaminitis -graft versus host disease of the liver -VRE bacteremia -febrile neutropenia -urinary tract infection -pancytopenia -myelodysplastic syndrome -atrial fibrillation with rapid ventricular rate -epigastric pain -altered mental status -acute on chronic kidney injury -dyspnea on exertion -left arm swelling Discharge Condition: Expired Discharge Instructions: Patient passed away inpatient ___ MD ___ Completed by: ___
[ "D709", "A4181", "N179", "D89813", "E861", "D4622", "I480", "D62", "N390", "D696", "I129", "T865", "K7290", "R5081", "N189", "R1013", "K8080", "B961", "G4730", "K219", "R600", "R197", "Z515", "Z1621", "Z85828", "Z87891", "Z66" ]
Allergies: minocycline Chief Complaint: Rising LFTs Major Surgical or Invasive Procedure: [MASKED] liver biopsy PICC line placement and removal History of Present Illness: Mr. [MASKED] is a [MASKED] year old gentleman with a history of MDS - Refractory Anemia with Excess Blasts Type [MASKED] s/p reduced intensity MRD allogeneic SCT now D+405 who presents from clinic with rising LFTs and fever. Overall has been feeling very fatigued. Also endorses sx of urinary frequency for the last few weeks. Had fever yesterday and again in clinic. He has a complicated post-transplant history. He has had severe GVHD of the gut treated with prednisone and cyclosporine, currently maintained on 5mg prednisone daily and budesonide. He was diagnosed with aspergillus and stenotrophomonas pneumonia on BAL on [MASKED] and treated with levofloxacin and voriconazole, and then on [MASKED] was started on posaconizole for fungal prophylaxis. On [MASKED] he was found to have citrobacter bacteremia from a suspected line infection and treated with meropenem, then cefepime, and finally ciprofloxacin for a 2 week course. On [MASKED] he was admitted with afib with RVR and found to have Nocardia nova pneumonia of RLL diagnosed on lung biopsy and treated with imipenim and minocycline, which on [MASKED] was switched to ceftriaxone/minocycline for dosing convenience when he was leaving rehab. On [MASKED] minocycline and posaconazole were held due to elevated LFTs. He has been at [MASKED] since his discharge on [MASKED] with a planned discharge this week. He was seen in clinic today w/ elevated LFTs and fever and admitted for hepatology w/u. On the floor denies abd pain, fevers, chills. +urinary frequency and feeling very tired. Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seen in MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: - [MASKED]: C1 Decitabine - [MASKED]: C2 Decitabine - [MASKED]: C3 Decitabine - [MASKED]: C4 Decitabine - [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor ***Peripheral engraftment [MASKED]: 99% donor ***Peripheral engraftment [MASKED]: 100% donor ***Peripheral engraftment [MASKED]: 100% donor ***Bone arrow engraftment [MASKED]: 100% donor ***Peripheral blood engraftment [MASKED]: 100% donor ***Peripheral blood engraftment (cytogenetics done at [MASKED], [MASKED]: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment [MASKED]: 100% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL --[MASKED]: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --[MASKED]: Started on posaconazole for fungal prophylaxis --[MASKED]: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --[MASKED]: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --[MASKED]: Changed to CTX/minocycline --[MASKED]: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - [MASKED]: C1: IVIG - [MASKED]: C2: IVIG - [MASKED]: C3: IVIG - [MASKED]: C4 IVIG - [MASKED]: IVIG ***Voriconazole stopped on [MASKED] ***Posaconazole started on [MASKED], on hold since [MASKED] PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD s/p EGD - s/p inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION EXAM ============== Vitals: 99.5 145/86 77 19 100RA GENERAL: No acute distress, fatigued. HEENT: Mucous membranes moist. OP clear. No petechiae. CHEST: CTAB although poor respiratory effort. CARDIAC: Irregularly irregular, no murmurs ABDOMEN: Hypoactive bowel sounds, slightly distended, no hepatosplenomegaly appreciated. Nontender. EXTREMITIES: 1+ pitting edema bilaterally to shins SKIN: Warm and dry, skin is very fragile, senile purpura over hands and ecchymotic lesions over the chest, face and neck NEURO: Alert and oriented to person but not date, season, year or place. Poor attention. CN2-12 intact. Mild weakness in the left upper extremity. Weakness with dorsiflexion of right foot, otherwise lower extremity strength intact. LINES: PICC in place in the LUE DISCHARGE EXAM ============== Vitals: Tmax 99.0 BP 90-120/60-80s HR 70-90s RR [MASKED] O2 95-98% on RA GENERAL: Chronically ill appearing, appears anxious and confused HEENT: Scleral icterus, right conjunctival hemorrhage. Mucous membranes dry. CHEST: CTAB, no w/r/c CARDIAC: Irregularly irregular, no murmurs ABDOMEN: Moderately tender to palpation diffusely but predominantly in epigastrium and periumbilical areas. + BS, no organomegaly, negative [MASKED] sign. EXTREMITIES: trace edema LUE and BLE. Otherwise WWP SKIN: Diffusely jaundiced. Prior left leg gauze removed. Warm and dry, skin is very fragile, purpura and ecchymoses over most of body but predominantly at right elbow and over chest area. ACCESS: Two 20 gauge PIVs NEURO: Minimally responsive, agitated, not oriented. Pertinent Results: ADMISSION LABS ============== [MASKED] 10:20AM BLOOD WBC-0.2* RBC-2.80* Hgb-8.9* Hct-25.5* MCV-91 MCH-31.8 MCHC-34.9 RDW-18.2* RDWSD-57.4* Plt Ct-8*# [MASKED] 10:20AM BLOOD Neuts-3* Bands-0 Lymphs-81* Monos-15* Eos-0 Baso-1 [MASKED] Myelos-0 NRBC-2* AbsNeut-0.01* AbsLymp-0.16* AbsMono-0.03* AbsEos-0.00* AbsBaso-0.00* [MASKED] 10:20AM BLOOD [MASKED] PTT-25.3 [MASKED] [MASKED] 10:20AM BLOOD Glucose-108* UreaN-31* Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-23 AnGap-16 [MASKED] 10:20AM BLOOD ALT-150* AST-51* LD([MASKED])-231 AlkPhos-1553* TotBili-3.7* [MASKED] 10:20AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.4* UricAcd-6.1 [MASKED] 10:20AM BLOOD Digoxin-2.2* PERTINENT LABS ============== [MASKED] 10:20AM BLOOD ALT-150* AST-51* LD([MASKED])-231 AlkPhos-1553* TotBili-3.7* [MASKED] 07:20AM BLOOD ALT-119* AST-58* LD([MASKED])-181 AlkPhos-885* TotBili-4.6* [MASKED] 06:00AM BLOOD ALT-236* AST-124* LD([MASKED])-219 AlkPhos-842* TotBili-6.7* [MASKED] 05:50AM BLOOD ALT-306* AST-121* LD([MASKED])-260* AlkPhos-826* TotBili-9.3* [MASKED] 12:10AM BLOOD ALT-218* AST-64* AlkPhos-673* TotBili-9.2* [MASKED] 12:00AM BLOOD ALT-186* AST-71* LD([MASKED])-292* AlkPhos-687* TotBili-8.9* [MASKED] 12:05AM BLOOD ALT-171* AST-79* LD([MASKED])-296* AlkPhos-620* TotBili-8.6* [MASKED] 12:00AM BLOOD ALT-154* AST-72* AlkPhos-588* TotBili-9.0* DirBili-6.4* IndBili-2.6 [MASKED] 12:00AM BLOOD ALT-164* AST-86* LD([MASKED])-303* CK(CPK)-13* AlkPhos-597* TotBili-11.2* [MASKED] 04:55AM BLOOD ALT-204* AST-112* LD([MASKED])-347* AlkPhos-541* TotBili-14.0* [MASKED] 07:10AM BLOOD ALT-261* AST-142* LD([MASKED])-390* AlkPhos-607* TotBili-17.1* [MASKED] 01:30AM BLOOD calTIBC-178* [MASKED] TRF-137* [MASKED] 06:05AM BLOOD Hapto-117 [MASKED] 08:28AM BLOOD Hapto-34 [MASKED] 01:30AM BLOOD Triglyc-112 HDL-34 CHOL/HD-4.4 LDLcalc-92 [MASKED] 04:14PM BLOOD Ammonia-21 [MASKED] 01:30AM BLOOD HBsAg-Negative HBsAb-Positive HAV Ab-Positive* [MASKED] 12:00AM BLOOD IgM HAV-Negative [MASKED] 01:30AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [MASKED] 01:30AM BLOOD [MASKED] [MASKED] 02:20PM BLOOD IgG-745 DISCHARGE LABS ============== [MASKED] 06:05AM BLOOD WBC-0.1* RBC-2.35* Hgb-6.9* Hct-18.9* MCV-80* MCH-29.4 MCHC-36.5 RDW-16.7* RDWSD-46.5* Plt Ct-41* [MASKED] 06:05AM BLOOD [MASKED] PTT-26.3 [MASKED] [MASKED] 06:05AM BLOOD Glucose-90 UreaN-31* Creat-1.1 Na-133 K-3.4 Cl-98 HCO3-25 AnGap-13 [MASKED] 06:05AM BLOOD ALT-270* AST-145* LD(LDH)-365* AlkPhos-519* TotBili-15.2* [MASKED] 06:05AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0 IMAGING ======= [MASKED] CHEST (PORTABLE AP) IMPRESSION: Compared to chest radiographs [MASKED]. Mildly enlarged cardiac silhouette obscures the left lower lobe. Lateral view would be helpful in detection of basal pneumonia or small pleural effusions. Upper lungs clear. No pneumothorax. [MASKED] LIVER OR GALLBLADDER US IMPRESSION: No evidence of biliary obstruction. Cholelithiasis. Gallbladder is not distended. [MASKED] CT HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial abnormality, with no evidence of acute intracranial hemorrhage. 2. Paranasal sinus disease as described. [MASKED] CT ABD & PELVIS W/O CON IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Small volume ascites. New subtle omental stranding and nodularity in the left upper quadrant is nonspecific and could represent an unusual appearance of ascitic fluid. Follow-up imaging is recommended if the patient develops left-sided pain. 3. Unchanged pulmonary nodules. [MASKED] UNILAT UP EXT VEINS US IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. [MASKED] MRCP (MR [MASKED] IMPRESSION: The gallbladder is decompressed with gallstones. Eccentric 9 mm stone in the proximal cystic duct, currently non-obstructing stone as there is no upstream or gallbladder dilatation however this may be early or become obstructing given its size. No evidence of intra or extrahepatic biliary dilatation or obstruction. No common duct stones. Hepatic and splenic hemosiderosis. Small amount of fluid in the right upper quadrant and trace in the left lower quadrant. [MASKED] Cardiovascular ECHO The left atrial volume index is normal. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is beat-to-beat variability in ejection fraction. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild to moderate ([MASKED]) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate aortic regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of [MASKED], the severity of aortic regurgitation is slightly increased and the severity of mitral regurgitation is slightly reduced. [MASKED] CHEST (PA & LAT) IMPRESSION: In comparison with the study [MASKED], there is little interval change. Small bilateral pleural effusions are again seen in a patient with enlargement of the cardiac silhouette, but no vascular congestion or acute focal pneumonia. [MASKED] CHEST (PA & LAT) IMPRESSION: New small bilateral pleural effusions, right greater than left [MASKED] UNILAT UP EXT VEINS US IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. [MASKED] LIVER OR GALLBLADDER US IMPRESSION: Gallstones. The gallbladder wall is thickened and edematous which is likely due to third spacing. Normal hepatic parenchyma without evidence of hepatic abscess. [MASKED] CT CHEST W/O CONTRAST IMPRESSION: 1. The previously seen right lower lobe nodule, reportedly due to Nocardia infection, has further decreased in size. New small opacity in the inferior right upper lobe (4:124) could be localized aspiration or early/resolving infection. 2. Small bilateral pleural effusions. 3. Other findings are similar to prior. [MASKED] CT ABD & PELVIS W/O CON IMPRESSION: 1. Mild gallbladder wall edema and small amount of free fluid in the pelvis likely reflects third-spacing. Cholecystitis is unlikely since the gallbladder is collapsed however further evaluation with ultrasound could be performed. 2. No definite source for fever identified MICROBIOLOGY ============ **all results below negative unless specified** [MASKED] Immunology (CMV) CMV Viral Load-FINAL NEGATIVE [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] Immunology (CMV) CMV Viral Load-FINAL NEGATIVE [MASKED] STOOL C. difficile DNA amplification assay-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT [MASKED] IMMUNOLOGY HBV Viral Load-FINAL INPATIENT [MASKED] Immunology (CMV) NOT PROCESSED INPATIENT [MASKED] STOOL VIRAL CULTURE-FINAL INPATIENT [MASKED] STOOL C. difficile DNA amplification assay-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] TISSUE VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT [MASKED] Immunology (CMV) NOT PROCESSED INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL {KLEBSIELLA OXYTOCA} INPATIENT [MASKED] Immunology (CMV) CMV Viral Load-FINAL Brief Hospital Course: BRIEF SUMMARY ============= Mr. [MASKED] was a [MASKED] year old male with MDS who underwent an allogeneic bone marrow transplant in [MASKED] which was complicated by graft failure as well as GVHD. He presented to us in early [MASKED] after being found to have a fever and rising LFTs, and after liver biopsy was found to have evidence of severe GVHD of the liver. He was treated with high dose methylprednisolone and mycophenolate, however his LFTs continued to rise. He developed VRE bacteremia, which was treated with daptomycin then linezolid but developed significant hypotension with sitting up likely due to sepsis. Because of his overall condition, he opted to be made comfort care only and passed away with his family at his bedside. ACUTE ISSUES ============ #Comfort measures only: Given patient's continuing decline in physical and mental function, he met with palliative care and hospice to discuss going home with hospice. Due to the rapid pace of his decline, he was made CMO while inpatient and passed away with his family at the bedside. # Transaminitis : # GVHD of liver : Pt noted to have rising LFTs prior to admission, liver bx showed evidence of GVHD as well as moderate to severe iron deposition. Started on methylprednisolone IV with mild improvement in LFTs initially, however bilirubin began to increase again. MRCP notable for non-obstructing stone in cystic duct but decompressed gallbladder, RUQUS with no evidence of obstruction. A broad microbiologic workup was performed which was unrevealing. MMF was added to his immunosuppressive regimen with no improvement. Due to his overall condition, he was made CMO as above. # VRE bacteremia: # Febrile neutropenia: # Klebsiella Oxytoca UTI: Initially febrile with klebsiella UTI on admission, placed on imipenem to cover GNRs and nocardia. On [MASKED], BCx positive for enterococcus. He was initially treated with vancomycin x1 day, however sensitivites revealed vancomycin resistance so he was switched to daptomycin 8mg/kg. No other blood cultures were positive, however he experienced episodes of hypotension as below so was switched to linezolid, cefepime, and Flagyl with the thought that he may have been septic. #Hypotension: Towards the end of his course, pt became hypotensive to [MASKED] systolic with sitting up, with several episodes of near-syncope and one episode where he became transiently non-responsive. Potentially due to sepsis, however liver failure can also cause hypotension and he probably has an element of hypovolemia as well. No significant improvement with fluid boluses, however. #Epigastric/LUQ abdominal pain: Pt experienced new onset epigastric and LUQ abdominal pain several days into starting steroids, may be [MASKED] gastritis vs ulceration. Patient was given an IV PPI BID and never had any evidence of GI bleeding. #Altered mental status: Waxing and waning mental status with evidence of asterixis, potentially secondary to liver failure. Because he was stooling frequently we did not initiate lactulose. Ammonia level of 24. # [MASKED] on CKD: Patient with baseline Cr in the 1.3-1.5 range over prior 6 months, elevated in the setting of hypovolemia, improved with IVF. #Dyspnea on exertion: Improved with pRBC transfusion, likely [MASKED] symptomatic anemia. BNP significantly elevated and patient had bilateral lower extremity edema, however CXR on [MASKED] showed no e/o volume overload. TTE with preserved systolic and diastolic function. #Left arm swelling: Likely related to PICC placement. Doppler U/S no e/o DVT. # MDS with RAEB type [MASKED] s/p allo SCT: D+540 on admission. Patient has pre-transplant 45X,-Y karyotype. Recent peripheral blood chimerism study ([MASKED]) showed 5.5%X, 94.5%XY. C/b secondary graft failure. Required intermittent transfusions for both pRBCs and platelets throughout his course. His brother (donor) traveled from out of state for harvesting of CD34+ stem cells for a possible stem cell boost given his persistent graft failure, however due to his rising LFTs and poor condition a decision was made to defer a stem cell boost. # Afib with RVR: CHA2DS-VASc score = 1 (age > [MASKED]). In atrial fibrillation on telemetry since admission. No longer being anti-coagulated given thrombocytopenia. Experienced likely Afib with RVR with rates in the 150s and pressures in the [MASKED] on [MASKED], which resolved spontaneously without intervention. Initially increased metoprolol from 50mg q6h to 62.5 mg q6h, however became hypotensive and bradycardic to decreased back to 50mg. Digoxin held on [MASKED] given an episode of bradycardia to the [MASKED], patient eventually CMO so all medications discontinued. # hx norcardia PNA: Given steroid use, initially restarted minocycline and clarithromycin for prophylaxis. Due to his LFT rise, both of these drugs were discontinued and he was treated with imipenem at first then cefepime as detailed above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. FoLIC Acid 5 mg PO DAILY 6. Guaifenesin 10 mL PO Q6H:PRN cough 7. Multivitamins 1 TAB PO DAILY 8. Posaconazole Delayed Release Tablet 300 mg PO DAILY 9. PredniSONE 5 mg PO DAILY 10. Simethicone 80 mg PO QID:PRN gas and bloating 11. Ursodiol 300 mg PO BID 12. Vitamin D [MASKED] UNIT PO DAILY 13. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 14. Psyllium Powder 1 PKT PO DAILY:PRN constipation 15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 16. Pantoprazole 40 mg PO Q24H 17. Metoprolol Succinate XL 150 mg PO BID 18. Atovaquone Suspension 1500 mg PO DAILY 19. Cetirizine 10 mg PO DAILY 20. Digoxin 0.125 mg PO DAILY 21. Diltiazem 60 mg PO TID 22. Filgrastim 480 mcg SC Q24H 23. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eye 24. Zinc Sulfate Dose is Unknown PO DAILY Discharge Disposition: Expired Discharge Diagnosis: -transaminitis -graft versus host disease of the liver -VRE bacteremia -febrile neutropenia -urinary tract infection -pancytopenia -myelodysplastic syndrome -atrial fibrillation with rapid ventricular rate -epigastric pain -altered mental status -acute on chronic kidney injury -dyspnea on exertion -left arm swelling Discharge Condition: Expired Discharge Instructions: Patient passed away inpatient [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "N179", "I480", "D62", "N390", "D696", "I129", "N189", "K219", "Z515", "Z87891", "Z66" ]
[ "D709: Neutropenia, unspecified", "A4181: Sepsis due to Enterococcus", "N179: Acute kidney failure, unspecified", "D89813: Graft-versus-host disease, unspecified", "E861: Hypovolemia", "D4622: Refractory anemia with excess of blasts 2", "I480: Paroxysmal atrial fibrillation", "D62: Acute posthemorrhagic anemia", "N390: Urinary tract infection, site not specified", "D696: Thrombocytopenia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "T865: Complications of stem cell transplant", "K7290: Hepatic failure, unspecified without coma", "R5081: Fever presenting with conditions classified elsewhere", "N189: Chronic kidney disease, unspecified", "R1013: Epigastric pain", "K8080: Other cholelithiasis without obstruction", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "G4730: Sleep apnea, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R600: Localized edema", "R197: Diarrhea, unspecified", "Z515: Encounter for palliative care", "Z1621: Resistance to vancomycin", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate" ]
10,064,049
25,136,159
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Concern for pneumonia Major Surgical or Invasive Procedure: Bronchoscopy on ___ History of Present Illness: Mr. ___ is a ___ year old gentleman with a history of MDS - Refractory Anemia with Excess Blasts Type ___ s/p reduced intensity MRD allogeneic SCT now D+405 who presents from clinic with concern for pneumonia. He has a complicated post-transplant history. He has had severe GVHD of the gut treated with prednisone and cyclosporine, currently maintained on 5mg prednisone daily and budesonide. He was diagnosed with aspergillus and stenotrophomonas pneumonia on BAL on ___ and treated with levofloxacin and voriconazole, and then on ___ was started on posaconizole for fungal prophylaxis. On ___ he was found to have citrobacter bacteremia from a suspected line infection and treated with meropenem, then cefepime, and finally ciprofloxacin for a 2 week course. On ___ he was admitted with afib with RVR and found to have Nocardia nova pneumonia of RLL diagnosed on lung biopsy and treated with imipenim and minocycline, which on ___ was switched to ceftriaxone/minocycline for dosing convenience when he was leaving rehab. On ___ minocycline and posaconazole were held due to elevated LFTs. He has been at ___ since his discharge on ___ with a planned discharge this week. He was seen by Dr. ___ in ___ clinic today and endorsed dyspnea on exertion and generally feeling weak. He was noted to have downtrending platelets and had a bone marrow biopsy to evaluate for recurrent MDS. ___ CXR showed new consolidation in RUL. He is admitted for further work-up and treatment. Currently, patient reports that he is tired and that his breathing is slightly heavy. Denies any fevers, chills, sweats. Says that he has been receiving Lasix IV at rehab and that he plans to have a cardioversion with his cardiologist in the next few weeks. He is currently not anticoagulated for his afib. He denies any cough, sputum production. Says his leg swelling is much improved. Reports some stable loose stools after meals. No pain with defecation. No blood in stool. Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: - ___: C1 Decitabine - ___: C2 Decitabine - ___: C3 Decitabine - ___: C4 Decitabine - ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor ***Peripheral engraftment ___: 99% donor ***Peripheral engraftment ___: 100% donor ***Peripheral engraftment ___: 100% donor ***Bone arrow engraftment ___: 100% donor ***Peripheral blood engraftment ___: 100% donor ***Peripheral blood engraftment (cytogenetics done at ___, ___: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --___: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --___: Changed to CTX/minocycline --___: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - ___: C1: IVIG - ___: C2: IVIG - ___: C3: IVIG - ___: C4 IVIG - ___: IVIG ***Voriconazole stopped on ___ ***Posaconazole started on ___, on hold since ___ PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD s/p EGD - s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: *ADMISSION PHYSICAL EXAM* VS: 98 103/62 91 20 97%ra Weight: 172lb Admission weight: 176lbs GENERAL: Alert, oriented, well appearing sitting up in chair HEENT: +thrush on tongue and oropharynx, multiple soft subcutaneous neck masses in supraclavicular area that are non-tender CARDIAC: tachycardic, irreg irreg, no murmurs RESP: LCAB in posterior and anterior lung fields, good air movement ABDOMEN: soft, non-tender EXTREMITIES: 1+ edema upper shins bilaterally, wearing compression stockings SKIN: numerous ecchymoses on arms, chest; large ecchymosis on R lateral anterior chest that is tender to palpation *DISCHARGE PHYSICAL EXAM* VS: 98.1 110s/70s 70 19 ___/50 sitting 92/60 standing 90/60 Weight today: ___. 180 on ___ <- 175.2 on ___ <- 169.5 on ___ <- 176 on admission GENERAL: Alert, oriented, well appearing sitting up in bed HEENT: MMM no oropharyngeal lesions NECK: JVP not elevated today; negative abdominojugular reflex CARDIAC: irreg irreg, no murmurs RESP: Good air movement, bibasilar crackles ABDOMEN: soft, non-tender EXTREMITIES: - 2+ pitting edema to lower shins shins bilaterally - LUE: swelling distal to L antecubital PICC appears improved from yesterday. nontender no ertyehma SKIN: numerous ecchymoses on arms, chest; large ecchymosis on R lateral anterior chest that is tender to palpation Pertinent Results: *ADMISSION LABS* ___ 08:55AM BLOOD WBC-6.8 RBC-2.42* Hgb-8.9* Hct-27.9* MCV-115* MCH-36.8* MCHC-31.9* RDW-22.7* RDWSD-94.0* Plt Ct-59* ___ 08:55AM BLOOD Neuts-94* Bands-0 Lymphs-2* Monos-4* Eos-0 Baso-0 ___ Myelos-0 NRBC-2* AbsNeut-6.39* AbsLymp-0.14* AbsMono-0.27 AbsEos-0.00* AbsBaso-0.00* ___ 08:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-OCCASIONAL ___ 08:55AM BLOOD ___ PTT-24.1* ___ ___ 08:55AM BLOOD Glucose-170* UreaN-45* Creat-0.9 Na-145 K-3.4 Cl-105 HCO3-30 AnGap-13 ___ 08:55AM BLOOD ALT-175* AST-60* LD(LDH)-432* AlkPhos-206* TotBili-0.5 ___ 08:55AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.3 UricAcd-9.0* *PERTINENT INTERVAL LABS* ___:03PM BLOOD WBC-3.9* Lymph-2.0* Abs ___ CD3%-86 Abs CD3-67* CD4%-67 Abs CD4-53* CD8%-18 Abs CD8-14* CD4/CD8-3.72* ___ 02:28PM BLOOD cTropnT-<0.01 ___ 12:00AM BLOOD TSH-4.2 ___ 12:00AM BLOOD T4-5.2 ___ 12:28AM BLOOD Digoxin-0.5* CBC TREND: ___ 11:44PM BLOOD WBC-4.8 RBC-2.07* Hgb-7.6* Hct-23.0* MCV-111* MCH-36.7* MCHC-33.0 RDW-20.7* RDWSD-82.1* Plt Ct-21* ___ 11:27PM BLOOD WBC-3.2* RBC-1.86* Hgb-6.8* Hct-20.4* MCV-110* MCH-36.6* MCHC-33.3 RDW-21.1* RDWSD-81.6* Plt Ct-28* ___ 12:00AM BLOOD WBC-2.9* RBC-2.19* Hgb-7.7* Hct-23.1* MCV-106* MCH-35.2* MCHC-33.3 RDW-22.7* RDWSD-83.3* Plt Ct-23* ___ 12:00AM BLOOD WBC-2.8* RBC-2.21* Hgb-7.9* Hct-23.6* MCV-107* MCH-35.7* MCHC-33.5 RDW-22.8* RDWSD-85.1* Plt Ct-25* ___ 12:00AM BLOOD WBC-2.1* RBC-2.22* Hgb-7.9* Hct-23.7* MCV-107* MCH-35.6* MCHC-33.3 RDW-22.8* RDWSD-85.8* Plt Ct-25* ___ 12:00AM BLOOD WBC-2.0* RBC-2.28* Hgb-8.2* Hct-24.5* MCV-108* MCH-36.0* MCHC-33.5 RDW-23.1* RDWSD-90.9* Plt Ct-36* ___ 12:00AM BLOOD WBC-1.9* RBC-1.91* Hgb-7.0* Hct-20.7* MCV-108* MCH-36.6* MCHC-33.8 RDW-23.2* RDWSD-91.3* Plt Ct-31* AM CORTISOL: ___ 07:42AM BLOOD Cortsol-12.8 IGG TREND ___ 07:42AM BLOOD IgG-617* IgG trend ___ 08:55AM BLOOD IgG-245* LFT TREND: ___ 08:55AM BLOOD ALT-175* AST-60* LD(___)-432* AlkPhos-206* TotBili-0.5 ___ 04:54AM BLOOD ALT-166* AST-61* LD(___)-455* AlkPhos-203* TotBili-0.7 ___ 05:20AM BLOOD ALT-203* AST-111* LD(___)-475* AlkPhos-205* TotBili-0.9 ___ 05:30AM BLOOD ALT-186* AST-72* LD(___)-398* AlkPhos-205* TotBili-0.8 ___ 04:40PM BLOOD LD(___)-434* ___ 12:28AM BLOOD ALT-137* AST-45* LD(___)-359* AlkPhos-195* TotBili-0.6 ___ 12:00AM BLOOD ALT-106* AST-38 LD(___)-396* AlkPhos-201* TotBili-0.8 ___ 12:00AM BLOOD ALT-61* AST-47* LD(___)-347* AlkPhos-195* TotBili-0.6 ___ 12:00AM BLOOD ALT-49* AST-34 LD(___)-377* AlkPhos-230* TotBili-0.6 ___ 12:00AM BLOOD ALT-36 AST-31 LD(___)-393* AlkPhos-218* TotBili-0.7 ___ 12:00AM BLOOD ALT-32 AST-34 LD(___)-431* AlkPhos-223* TotBili-0.7 ___ 12:21AM BLOOD ALT-25 AST-29 LD(___)-374* AlkPhos-184* TotBili-0.6 ___ 12:00AM BLOOD ALT-22 AST-27 LD(LDH)-362* AlkPhos-175* TotBili-0.5 ___ 12:00AM BLOOD ALT-20 AST-29 LD(LDH)-334* AlkPhos-216* TotBili-0.4 ___ 12:00AM BLOOD ALT-32 AST-40 LD(LDH)-381* AlkPhos-300* TotBili-0.4 ___ 12:00AM BLOOD ALT-30 AST-39 LD(___)-341* AlkPhos-296* TotBili-0.3 ___ 12:45AM BLOOD ALT-42* AST-48* LD(___)-372* AlkPhos-382* TotBili-0.5 ___ 12:00AM BLOOD ALT-56* AST-65* LD(___)-390* AlkPhos-474* TotBili-0.4 DISCHARGE LABS: ___ 12:00AM BLOOD WBC-2.4* RBC-2.35* Hgb-8.3* Hct-24.3* MCV-103* MCH-35.3* MCHC-34.2 RDW-24.5* RDWSD-88.3* Plt Ct-34* ___ 12:00AM BLOOD Neuts-66 Bands-2 Lymphs-3* Monos-26* Eos-0 Baso-0 ___ Metas-2* Myelos-1* NRBC-6* AbsNeut-1.63 AbsLymp-0.07* AbsMono-0.62 AbsEos-0.00* AbsBaso-0.00* ___ 12:40AM BLOOD ___ PTT-19.3* ___ ___ 12:00AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND CD4/CD8-PND ___ 12:00AM BLOOD Glucose-117* UreaN-23* Creat-1.1 Na-135 K-4.0 Cl-103 HCO3-21* AnGap-15 ___ 12:00AM BLOOD ALT-56* AST-65* LD(LDH)-390* AlkPhos-474* TotBili-0.4 ___ 12:00AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9 *MICROBIOLOGY* ___ 4:20 pm BRONCHOALVEOLAR LAVAGE BRONCIAL LAVAGE RLL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final ___: >100,000 ORGANISMS/ML. Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. ASAIA SPP. UNABLE TO DETERMINE SPECIES.. IDENTIFICATION PERFORMED BY ___. STENOTROPHOMONAS MALTOPHILIA. ~6OOO/ML. FURTHER WORKUP ON REQUEST ONLY Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. IDENTIFICATION & Sensitivity testing per ___ ___. POTASSIUM HYDROXIDE PREPARATION (Final ___: TEST CANCELLED, PATIENT CREDITED. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). This is a low yield procedure based on our in-house studies. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. SPECIATE PER ___ ___. 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): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final ___: TEST CANCELLED, PATIENT CREDITED. SPECIMEN COMBINED WITH SAMPLE # ___. Reported to and read back by ___ ___ AT 1220. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: TEST CANCELLED, PATIENT CREDITED. SPECIMEN COMBINED WITH SAMPLE # ___. ASPERGILLUS GALACTOMANNAN ANTIGEN Test Result Reference Range/Units INDEX VALUE 0.22 <0.50 ASPERGILLUS AG, EIA, BAL Not Detected Not Detected *IMAGING* ___ CT Chest WO Contrast New opacity in the right upper right middle and right lower lobe has been demonstrated with bronchus centric appearance and parenchymal involvement concerning for extensive infectious process. The findings have evidence of air bronchogram as well as ground-glass opacities. The pre-existing right lower lobe nodule consistent with known or cardia pneumonia appears to be unchanged in size. ___HEST Substantial interval improvement of the multifocal opacities throughout the right lung with minimal residual ground-glass, can be treated infection. Stable right lower lobe nodular opacity, biopsy-proven Nocardia. Ascending thoracic aorta top-normal size, unchanged. Mild enlargement, main and right pulmonary arteries, significance indeterminate. ___ LUE VENOUS ULTRASOUND Partially occlusive thrombus involving the left axillary and left basilic vein along side a left-sided PICC. ___ ECHO The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (___) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of ___, right ventricular size is normal on current images. There is less tricuspid rigurgitation. Other findings are similar. ENGRAFTMENT/CHIMERISM: M O L E C U L A R D I A G N O S T I C S Transplant Information Collected Diagnosis Transplant Date Donor Last Name ___ First Name --------- --------- --------------- --------------- ---------------- ___ MDS ___ ___ ___ Donor Sample Date ----------------- ___ Engraftment/Chimerism Analysis Collected Sample Type Locus Tested Recipient Sensitivity (%) ___ Bone Marrow Multiple Loci 1 Donor Sensitivity (%) Recipient Results (%) Donor Results (%) 1 1.0 99.0 Interpretation and Comments: The recipient sensitivity indicates the lowest percent of recipient cells detected by the assay; recipient cells below this amount would not be detected. The donor sensitivity indicates the lowest percent of donor cells detected by the assay; donor cells below this amount would not be detected. Brief Hospital Course: ___ w/ MDS RAEB type 2, s/p RI-allo-MRD-HSCT admitted for HCAP, course complicated by a-fib with RVR, hyperuricemia, and ___. Course also notable for orthostatic hypotension, LUE PICC-associated DVT. # HCAP: He presented to clinic with several days of dyspnea at ___, and found to have new RUL consolidation on CXR. He has a history of pulmonary aspergillosis and stenotrophomonas pneumonia, as well as recent nocardia nova pneumonia diagnosed on lung biopsy. He was started on vancomycin, imipenem, ambisome, and levofloxacin with improvement in his symptoms. A bronchoscopy was attempted on ___ but was postponed due to development of a-fib with RVR. It was eventually performed on ___ and BAL cultures grew stenotrophomonas. Repeat CT chest showed interval improvement in multi-focal consolidations. On ___ he was narrowed to Ceftriaxone/levofloxacin/posaconazole out of concern for medication leading to cytopenias (see below). His cough and dyspnea and resolved at discharge. # Atrial fibrillation with RVR: Patient has chronic atrial fibrillation per Atrius records, and was previously treated with digoxin which was discontinued due to toxicity. He is currently on high dose metoprolol and diltiazem at home. Following admission, he developed atrial fibrillation with RVR and hypotension to SBP high ___. This did resolve with short acting nodal blockade. He was started on digoxin. He remained in a-fib and rates gradually improved to ___. Digoxin was discontinued due to ___ as well as history of digoxin toxicity. He is unable to be anticoagulated due to thrombocytopenia. As below, his metop/dilt doses were downtitrated due to orthostatic hypotension. #Orthostatic hypotension: Towards the end of his course he developed orthostatic hypotension which was intermittently symptomatic. This was likely multifactorial, related to overdiuresis and high doses of metoprolol and diltiazem. This gradually improved with holding Lasix and slight decreases in doses of metop/dilt. To rule out other causes of hypotension, we checked an AM cortisol which was normal pointing against adrenal insufficiency, and he had an ECHO which was unchanged from prior. #LUE PICC-associated DVT: On ___ he developed swelling in his left hand. Ultrasound of the LUE showed partially occlusive thrombus associated with his left antecubital PICC. Swelling resolved w/elevation of the left arm. His PICC was left in place in light very difficult access in this patient and poor wound healing making tunneled line or port suboptimal. He was started on a lower dose of enoxaparin (30 mg subQ daily) because his platelets were in the ___ on ___. There ws no evidence of bleeding. PICC worked well throughout. #Acute on Chronic Diastolic CHF: Initially required diuresis with IV Lasix. Lasix was subsequently held from ___ in setting of orthostatic hypotension, then restarted ___ given weight gain and lower extremity swelling. At discharge he had 2+ ___ edema. #Pancytopenia: Course notable for worsening pancytopenia. As below he underwent BM biopsy ___ which showed 100% donor cells. This was thought most likely a side effect of his antibiotics, and cytopenias did stabilize after swtiching to ceftriaxone on ___. EBV and CMV were sent to r/o viral cause, and these were negative. # MDS with ___ with Excess Blasts Type II: s/p reduced intensity allo MRD SCT D+405 on admission. His course is complicated by pure red cell aplasia, improved with rituximab and pheresis, and GVHD of gut. He continued on prednisone 5mg; budesonide was stopped and stools were closely monitored - in part in an effort to reduce patient's steroid load given very poor wound healing. Bone marrow biopsy in clinic on ___ showed 100% donor cells. For his hypogammaglobulinemia, he received IVIG 40mg on ___, 10mg on ___, 10 mg on ___. # ___: His baseline creatinine is normal, but creatinine worsened to 1.7. This was felt to be due to congestive nephropathy, and improved with diuresis. TRANSITIONAL ISSUES =========================== **Medication changes** -Afib: Discharged on Metoprolol Tartrate 50 mg PO/NG Q6H and Diltiazem 60 mg PO/NG Q6H. Please consider converting to extended release versions medications prior to discharge from rehab. -Antibiotics: Discharged on ceftriaxone 2 g IV q24 and levofloxacin. These should be continued up to his follow-up ID appointment. Continued on posaconazole as well. -Budesonide (which he takes for GVHD of the gut) was stopped while inpatient as his bowel movements were stable, ___ loose stools/day. Please continue to monitor stool output. -Please monitor DAILY weights and lower extremity edema. Discharged on 80 PO Lasix daily. He may require additional or higher doses of Lasix if clinical evidence of CHF, if weight increasing >3 lbs. Please monitor closely. -We have stopped his KCl but please consider resuming if K+ is low when checked on ___. -Started on lovenox 30 mg subcutaneous daily (lower dose due to thrombocytopenia) for LUE DVT. Please consider increasing dose if platelets rise about 50. ***Other transitional issues*** - OPAT Labs: For ceftriaxone, please check CBC with diff, BUN/Cr, LFTs weekly. For levofloxacin please check AST, ALT, TBili, ALK PHOS 7 days post discharge. ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ - He has continued on weekly IVIG 10mg q ___ - Monitor QTc twice weekly while on levofloxacin and posaconazole - Please consider starting ___ prophylaxis given CD4 count most recently of 53. A repeat CD4 count was pending at discharge. - He should continue to have weekly beta glucan testing for hx of invasive aspergillosis -Please check CBC, electrolyte panel, LFTs on ___. Fax results to ___ clinic attention ___ ___. - Discharge weight: 187.9 lbs # CODE: FULL CODE # EMERGENCY CONTACT: ___ (wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. copper gluconate 3 mg oral DAILY 4. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 5. Docusate Sodium 100 mg PO BID 6. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Simethicone 80 mg PO QID:PRN gas and bloating 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 11. Ursodiol 300 mg PO BID 12. Vitamin D ___ UNIT PO DAILY 13. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 14. Lorazepam 0.5 mg PO QHS 15. Atovaquone Suspension 1500 mg PO DAILY 16. Diltiazem Extended-Release 360 mg PO DAILY 17. Furosemide 20 mg PO DAILY 18. Metoprolol Succinate XL 150 mg PO BID 19. PredniSONE 5 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Budesonide 3 mg PO TID 22. FoLIC Acid 5 mg PO DAILY 23. Pantoprazole 40 mg PO Q24H 24. CeftriaXONE 2 gm IV Q24H Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. FoLIC Acid 5 mg PO DAILY 4. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. PredniSONE 5 mg PO DAILY 8. Simethicone 80 mg PO QID:PRN gas and bloating 9. Ursodiol 300 mg PO BID 10. Vitamin D ___ UNIT PO DAILY 11. Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, TB, ALK PHOS CEFTRIAXONE: WEEKLY CBC with diff, BUN/Cr, LFTs weekly. 12. CeftriaXONE 2 gm IV Q24H 13. Diltiazem 60 mg PO Q6H 14. Metoprolol Tartrate 50 mg PO Q6H 15. Posaconazole Delayed Release Tablet 300 mg PO DAILY 16. Levofloxacin 750 mg PO DAILY 17. Enoxaparin Sodium 30 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 18. Furosemide 80 mg PO DAILY 19. Acyclovir 400 mg PO Q8H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Health Care Associated Pneumonia PICC-associated partial deep vein thrombosis orthostatic hypotension SECONDARY DIAGNOSIS Atrial Fibrillation Acute Kidney Injury Myelodysplastic Syndrome Hypogammaglobulinemia 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 caring for you at ___. You came to the hospital because of concern for a pneumonia. We treated you with antibiotics and you improved. We did a procedure called a bronchoscopy and obtained a sample of your lung fluid, which showed bacterial infection. You will require continued antibiotics after discharge. You also had some low blood pressures while you were in the hospital. These improved when we decreased the doses of your diltiazem and metoprolol. We also found that you have a partial blood clot associated with your PICC. This will be monitored closely and you will be given a low dose of a blood thinner. Please let your doctor know if at any time you have worsening swelling or pain in the hand or arm, or if you have any bleeding at all. Important instructions: - Please participate with physical therapy every day. This is very important to regain your mobility and function. - Stay away from high salt foods as this will make you retain fluid - Continue taking antibiotics for your pneumonia - Continue all other medications as prescribed We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "J156", "I5033", "N179", "D89813", "D61811", "D4622", "D801", "T82868A", "I82612", "T865", "I482", "Z87891", "I10", "K219", "R740", "Y849", "I951", "Z803", "K598", "Z801", "I340", "Y92230", "G4733", "T367X5A", "Y830", "Y929" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Concern for pneumonia Major Surgical or Invasive Procedure: Bronchoscopy on [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old gentleman with a history of MDS - Refractory Anemia with Excess Blasts Type [MASKED] s/p reduced intensity MRD allogeneic SCT now D+405 who presents from clinic with concern for pneumonia. He has a complicated post-transplant history. He has had severe GVHD of the gut treated with prednisone and cyclosporine, currently maintained on 5mg prednisone daily and budesonide. He was diagnosed with aspergillus and stenotrophomonas pneumonia on BAL on [MASKED] and treated with levofloxacin and voriconazole, and then on [MASKED] was started on posaconizole for fungal prophylaxis. On [MASKED] he was found to have citrobacter bacteremia from a suspected line infection and treated with meropenem, then cefepime, and finally ciprofloxacin for a 2 week course. On [MASKED] he was admitted with afib with RVR and found to have Nocardia nova pneumonia of RLL diagnosed on lung biopsy and treated with imipenim and minocycline, which on [MASKED] was switched to ceftriaxone/minocycline for dosing convenience when he was leaving rehab. On [MASKED] minocycline and posaconazole were held due to elevated LFTs. He has been at [MASKED] since his discharge on [MASKED] with a planned discharge this week. He was seen by Dr. [MASKED] in [MASKED] clinic today and endorsed dyspnea on exertion and generally feeling weak. He was noted to have downtrending platelets and had a bone marrow biopsy to evaluate for recurrent MDS. [MASKED] CXR showed new consolidation in RUL. He is admitted for further work-up and treatment. Currently, patient reports that he is tired and that his breathing is slightly heavy. Denies any fevers, chills, sweats. Says that he has been receiving Lasix IV at rehab and that he plans to have a cardioversion with his cardiologist in the next few weeks. He is currently not anticoagulated for his afib. He denies any cough, sputum production. Says his leg swelling is much improved. Reports some stable loose stools after meals. No pain with defecation. No blood in stool. Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seen in MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: - [MASKED]: C1 Decitabine - [MASKED]: C2 Decitabine - [MASKED]: C3 Decitabine - [MASKED]: C4 Decitabine - [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor ***Peripheral engraftment [MASKED]: 99% donor ***Peripheral engraftment [MASKED]: 100% donor ***Peripheral engraftment [MASKED]: 100% donor ***Bone arrow engraftment [MASKED]: 100% donor ***Peripheral blood engraftment [MASKED]: 100% donor ***Peripheral blood engraftment (cytogenetics done at [MASKED], [MASKED]: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. ***Peripheral blood engraftment [MASKED]: 100% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL --[MASKED]: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --[MASKED]: Started on posaconazole for fungal prophylaxis --[MASKED]: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --[MASKED]: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --[MASKED]: Changed to CTX/minocycline --[MASKED]: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - [MASKED]: C1: IVIG - [MASKED]: C2: IVIG - [MASKED]: C3: IVIG - [MASKED]: C4 IVIG - [MASKED]: IVIG ***Voriconazole stopped on [MASKED] ***Posaconazole started on [MASKED], on hold since [MASKED] PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD s/p EGD - s/p inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: *ADMISSION PHYSICAL EXAM* VS: 98 103/62 91 20 97%ra Weight: 172lb Admission weight: 176lbs GENERAL: Alert, oriented, well appearing sitting up in chair HEENT: +thrush on tongue and oropharynx, multiple soft subcutaneous neck masses in supraclavicular area that are non-tender CARDIAC: tachycardic, irreg irreg, no murmurs RESP: LCAB in posterior and anterior lung fields, good air movement ABDOMEN: soft, non-tender EXTREMITIES: 1+ edema upper shins bilaterally, wearing compression stockings SKIN: numerous ecchymoses on arms, chest; large ecchymosis on R lateral anterior chest that is tender to palpation *DISCHARGE PHYSICAL EXAM* VS: 98.1 110s/70s 70 19 [MASKED]/50 sitting 92/60 standing 90/60 Weight today: [MASKED]. 180 on [MASKED] <- 175.2 on [MASKED] <- 169.5 on [MASKED] <- 176 on admission GENERAL: Alert, oriented, well appearing sitting up in bed HEENT: MMM no oropharyngeal lesions NECK: JVP not elevated today; negative abdominojugular reflex CARDIAC: irreg irreg, no murmurs RESP: Good air movement, bibasilar crackles ABDOMEN: soft, non-tender EXTREMITIES: - 2+ pitting edema to lower shins shins bilaterally - LUE: swelling distal to L antecubital PICC appears improved from yesterday. nontender no ertyehma SKIN: numerous ecchymoses on arms, chest; large ecchymosis on R lateral anterior chest that is tender to palpation Pertinent Results: *ADMISSION LABS* [MASKED] 08:55AM BLOOD WBC-6.8 RBC-2.42* Hgb-8.9* Hct-27.9* MCV-115* MCH-36.8* MCHC-31.9* RDW-22.7* RDWSD-94.0* Plt Ct-59* [MASKED] 08:55AM BLOOD Neuts-94* Bands-0 Lymphs-2* Monos-4* Eos-0 Baso-0 [MASKED] Myelos-0 NRBC-2* AbsNeut-6.39* AbsLymp-0.14* AbsMono-0.27 AbsEos-0.00* AbsBaso-0.00* [MASKED] 08:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-OCCASIONAL [MASKED] 08:55AM BLOOD [MASKED] PTT-24.1* [MASKED] [MASKED] 08:55AM BLOOD Glucose-170* UreaN-45* Creat-0.9 Na-145 K-3.4 Cl-105 HCO3-30 AnGap-13 [MASKED] 08:55AM BLOOD ALT-175* AST-60* LD(LDH)-432* AlkPhos-206* TotBili-0.5 [MASKED] 08:55AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.3 UricAcd-9.0* *PERTINENT INTERVAL LABS* [MASKED]:03PM BLOOD WBC-3.9* Lymph-2.0* Abs [MASKED] CD3%-86 Abs CD3-67* CD4%-67 Abs CD4-53* CD8%-18 Abs CD8-14* CD4/CD8-3.72* [MASKED] 02:28PM BLOOD cTropnT-<0.01 [MASKED] 12:00AM BLOOD TSH-4.2 [MASKED] 12:00AM BLOOD T4-5.2 [MASKED] 12:28AM BLOOD Digoxin-0.5* CBC TREND: [MASKED] 11:44PM BLOOD WBC-4.8 RBC-2.07* Hgb-7.6* Hct-23.0* MCV-111* MCH-36.7* MCHC-33.0 RDW-20.7* RDWSD-82.1* Plt Ct-21* [MASKED] 11:27PM BLOOD WBC-3.2* RBC-1.86* Hgb-6.8* Hct-20.4* MCV-110* MCH-36.6* MCHC-33.3 RDW-21.1* RDWSD-81.6* Plt Ct-28* [MASKED] 12:00AM BLOOD WBC-2.9* RBC-2.19* Hgb-7.7* Hct-23.1* MCV-106* MCH-35.2* MCHC-33.3 RDW-22.7* RDWSD-83.3* Plt Ct-23* [MASKED] 12:00AM BLOOD WBC-2.8* RBC-2.21* Hgb-7.9* Hct-23.6* MCV-107* MCH-35.7* MCHC-33.5 RDW-22.8* RDWSD-85.1* Plt Ct-25* [MASKED] 12:00AM BLOOD WBC-2.1* RBC-2.22* Hgb-7.9* Hct-23.7* MCV-107* MCH-35.6* MCHC-33.3 RDW-22.8* RDWSD-85.8* Plt Ct-25* [MASKED] 12:00AM BLOOD WBC-2.0* RBC-2.28* Hgb-8.2* Hct-24.5* MCV-108* MCH-36.0* MCHC-33.5 RDW-23.1* RDWSD-90.9* Plt Ct-36* [MASKED] 12:00AM BLOOD WBC-1.9* RBC-1.91* Hgb-7.0* Hct-20.7* MCV-108* MCH-36.6* MCHC-33.8 RDW-23.2* RDWSD-91.3* Plt Ct-31* AM CORTISOL: [MASKED] 07:42AM BLOOD Cortsol-12.8 IGG TREND [MASKED] 07:42AM BLOOD IgG-617* IgG trend [MASKED] 08:55AM BLOOD IgG-245* LFT TREND: [MASKED] 08:55AM BLOOD ALT-175* AST-60* LD([MASKED])-432* AlkPhos-206* TotBili-0.5 [MASKED] 04:54AM BLOOD ALT-166* AST-61* LD([MASKED])-455* AlkPhos-203* TotBili-0.7 [MASKED] 05:20AM BLOOD ALT-203* AST-111* LD([MASKED])-475* AlkPhos-205* TotBili-0.9 [MASKED] 05:30AM BLOOD ALT-186* AST-72* LD([MASKED])-398* AlkPhos-205* TotBili-0.8 [MASKED] 04:40PM BLOOD LD([MASKED])-434* [MASKED] 12:28AM BLOOD ALT-137* AST-45* LD([MASKED])-359* AlkPhos-195* TotBili-0.6 [MASKED] 12:00AM BLOOD ALT-106* AST-38 LD([MASKED])-396* AlkPhos-201* TotBili-0.8 [MASKED] 12:00AM BLOOD ALT-61* AST-47* LD([MASKED])-347* AlkPhos-195* TotBili-0.6 [MASKED] 12:00AM BLOOD ALT-49* AST-34 LD([MASKED])-377* AlkPhos-230* TotBili-0.6 [MASKED] 12:00AM BLOOD ALT-36 AST-31 LD([MASKED])-393* AlkPhos-218* TotBili-0.7 [MASKED] 12:00AM BLOOD ALT-32 AST-34 LD([MASKED])-431* AlkPhos-223* TotBili-0.7 [MASKED] 12:21AM BLOOD ALT-25 AST-29 LD([MASKED])-374* AlkPhos-184* TotBili-0.6 [MASKED] 12:00AM BLOOD ALT-22 AST-27 LD(LDH)-362* AlkPhos-175* TotBili-0.5 [MASKED] 12:00AM BLOOD ALT-20 AST-29 LD(LDH)-334* AlkPhos-216* TotBili-0.4 [MASKED] 12:00AM BLOOD ALT-32 AST-40 LD(LDH)-381* AlkPhos-300* TotBili-0.4 [MASKED] 12:00AM BLOOD ALT-30 AST-39 LD([MASKED])-341* AlkPhos-296* TotBili-0.3 [MASKED] 12:45AM BLOOD ALT-42* AST-48* LD([MASKED])-372* AlkPhos-382* TotBili-0.5 [MASKED] 12:00AM BLOOD ALT-56* AST-65* LD([MASKED])-390* AlkPhos-474* TotBili-0.4 DISCHARGE LABS: [MASKED] 12:00AM BLOOD WBC-2.4* RBC-2.35* Hgb-8.3* Hct-24.3* MCV-103* MCH-35.3* MCHC-34.2 RDW-24.5* RDWSD-88.3* Plt Ct-34* [MASKED] 12:00AM BLOOD Neuts-66 Bands-2 Lymphs-3* Monos-26* Eos-0 Baso-0 [MASKED] Metas-2* Myelos-1* NRBC-6* AbsNeut-1.63 AbsLymp-0.07* AbsMono-0.62 AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:40AM BLOOD [MASKED] PTT-19.3* [MASKED] [MASKED] 12:00AM BLOOD WBC-PND Lymph-PND Abs [MASKED] CD3%-PND Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND CD4/CD8-PND [MASKED] 12:00AM BLOOD Glucose-117* UreaN-23* Creat-1.1 Na-135 K-4.0 Cl-103 HCO3-21* AnGap-15 [MASKED] 12:00AM BLOOD ALT-56* AST-65* LD(LDH)-390* AlkPhos-474* TotBili-0.4 [MASKED] 12:00AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9 *MICROBIOLOGY* [MASKED] 4:20 pm BRONCHOALVEOLAR LAVAGE BRONCIAL LAVAGE RLL. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [MASKED]: >100,000 ORGANISMS/ML. Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. ASAIA SPP. UNABLE TO DETERMINE SPECIES.. IDENTIFICATION PERFORMED BY [MASKED]. STENOTROPHOMONAS MALTOPHILIA. ~6OOO/ML. FURTHER WORKUP ON REQUEST ONLY Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. IDENTIFICATION & Sensitivity testing per [MASKED] [MASKED]. POTASSIUM HYDROXIDE PREPARATION (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ([MASKED]). This is a low yield procedure based on our in-house studies. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): [MASKED] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPECIATE PER [MASKED] [MASKED]. 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): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. SPECIMEN COMBINED WITH SAMPLE # [MASKED]. Reported to and read back by [MASKED] [MASKED] AT 1220. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. SPECIMEN COMBINED WITH SAMPLE # [MASKED]. ASPERGILLUS GALACTOMANNAN ANTIGEN Test Result Reference Range/Units INDEX VALUE 0.22 <0.50 ASPERGILLUS AG, EIA, BAL Not Detected Not Detected *IMAGING* [MASKED] CT Chest WO Contrast New opacity in the right upper right middle and right lower lobe has been demonstrated with bronchus centric appearance and parenchymal involvement concerning for extensive infectious process. The findings have evidence of air bronchogram as well as ground-glass opacities. The pre-existing right lower lobe nodule consistent with known or cardia pneumonia appears to be unchanged in size. HEST Substantial interval improvement of the multifocal opacities throughout the right lung with minimal residual ground-glass, can be treated infection. Stable right lower lobe nodular opacity, biopsy-proven Nocardia. Ascending thoracic aorta top-normal size, unchanged. Mild enlargement, main and right pulmonary arteries, significance indeterminate. [MASKED] LUE VENOUS ULTRASOUND Partially occlusive thrombus involving the left axillary and left basilic vein along side a left-sided PICC. [MASKED] ECHO The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([MASKED]) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [MASKED], right ventricular size is normal on current images. There is less tricuspid rigurgitation. Other findings are similar. ENGRAFTMENT/CHIMERISM: M O L E C U L A R D I A G N O S T I C S Transplant Information Collected Diagnosis Transplant Date Donor Last Name [MASKED] First Name --------- --------- --------------- --------------- ---------------- [MASKED] MDS [MASKED] [MASKED] [MASKED] Donor Sample Date ----------------- [MASKED] Engraftment/Chimerism Analysis Collected Sample Type Locus Tested Recipient Sensitivity (%) [MASKED] Bone Marrow Multiple Loci 1 Donor Sensitivity (%) Recipient Results (%) Donor Results (%) 1 1.0 99.0 Interpretation and Comments: The recipient sensitivity indicates the lowest percent of recipient cells detected by the assay; recipient cells below this amount would not be detected. The donor sensitivity indicates the lowest percent of donor cells detected by the assay; donor cells below this amount would not be detected. Brief Hospital Course: [MASKED] w/ MDS RAEB type 2, s/p RI-allo-MRD-HSCT admitted for HCAP, course complicated by a-fib with RVR, hyperuricemia, and [MASKED]. Course also notable for orthostatic hypotension, LUE PICC-associated DVT. # HCAP: He presented to clinic with several days of dyspnea at [MASKED], and found to have new RUL consolidation on CXR. He has a history of pulmonary aspergillosis and stenotrophomonas pneumonia, as well as recent nocardia nova pneumonia diagnosed on lung biopsy. He was started on vancomycin, imipenem, ambisome, and levofloxacin with improvement in his symptoms. A bronchoscopy was attempted on [MASKED] but was postponed due to development of a-fib with RVR. It was eventually performed on [MASKED] and BAL cultures grew stenotrophomonas. Repeat CT chest showed interval improvement in multi-focal consolidations. On [MASKED] he was narrowed to Ceftriaxone/levofloxacin/posaconazole out of concern for medication leading to cytopenias (see below). His cough and dyspnea and resolved at discharge. # Atrial fibrillation with RVR: Patient has chronic atrial fibrillation per Atrius records, and was previously treated with digoxin which was discontinued due to toxicity. He is currently on high dose metoprolol and diltiazem at home. Following admission, he developed atrial fibrillation with RVR and hypotension to SBP high [MASKED]. This did resolve with short acting nodal blockade. He was started on digoxin. He remained in a-fib and rates gradually improved to [MASKED]. Digoxin was discontinued due to [MASKED] as well as history of digoxin toxicity. He is unable to be anticoagulated due to thrombocytopenia. As below, his metop/dilt doses were downtitrated due to orthostatic hypotension. #Orthostatic hypotension: Towards the end of his course he developed orthostatic hypotension which was intermittently symptomatic. This was likely multifactorial, related to overdiuresis and high doses of metoprolol and diltiazem. This gradually improved with holding Lasix and slight decreases in doses of metop/dilt. To rule out other causes of hypotension, we checked an AM cortisol which was normal pointing against adrenal insufficiency, and he had an ECHO which was unchanged from prior. #LUE PICC-associated DVT: On [MASKED] he developed swelling in his left hand. Ultrasound of the LUE showed partially occlusive thrombus associated with his left antecubital PICC. Swelling resolved w/elevation of the left arm. His PICC was left in place in light very difficult access in this patient and poor wound healing making tunneled line or port suboptimal. He was started on a lower dose of enoxaparin (30 mg subQ daily) because his platelets were in the [MASKED] on [MASKED]. There ws no evidence of bleeding. PICC worked well throughout. #Acute on Chronic Diastolic CHF: Initially required diuresis with IV Lasix. Lasix was subsequently held from [MASKED] in setting of orthostatic hypotension, then restarted [MASKED] given weight gain and lower extremity swelling. At discharge he had 2+ [MASKED] edema. #Pancytopenia: Course notable for worsening pancytopenia. As below he underwent BM biopsy [MASKED] which showed 100% donor cells. This was thought most likely a side effect of his antibiotics, and cytopenias did stabilize after swtiching to ceftriaxone on [MASKED]. EBV and CMV were sent to r/o viral cause, and these were negative. # MDS with [MASKED] with Excess Blasts Type II: s/p reduced intensity allo MRD SCT D+405 on admission. His course is complicated by pure red cell aplasia, improved with rituximab and pheresis, and GVHD of gut. He continued on prednisone 5mg; budesonide was stopped and stools were closely monitored - in part in an effort to reduce patient's steroid load given very poor wound healing. Bone marrow biopsy in clinic on [MASKED] showed 100% donor cells. For his hypogammaglobulinemia, he received IVIG 40mg on [MASKED], 10mg on [MASKED], 10 mg on [MASKED]. # [MASKED]: His baseline creatinine is normal, but creatinine worsened to 1.7. This was felt to be due to congestive nephropathy, and improved with diuresis. TRANSITIONAL ISSUES =========================== **Medication changes** -Afib: Discharged on Metoprolol Tartrate 50 mg PO/NG Q6H and Diltiazem 60 mg PO/NG Q6H. Please consider converting to extended release versions medications prior to discharge from rehab. -Antibiotics: Discharged on ceftriaxone 2 g IV q24 and levofloxacin. These should be continued up to his follow-up ID appointment. Continued on posaconazole as well. -Budesonide (which he takes for GVHD of the gut) was stopped while inpatient as his bowel movements were stable, [MASKED] loose stools/day. Please continue to monitor stool output. -Please monitor DAILY weights and lower extremity edema. Discharged on 80 PO Lasix daily. He may require additional or higher doses of Lasix if clinical evidence of CHF, if weight increasing >3 lbs. Please monitor closely. -We have stopped his KCl but please consider resuming if K+ is low when checked on [MASKED]. -Started on lovenox 30 mg subcutaneous daily (lower dose due to thrombocytopenia) for LUE DVT. Please consider increasing dose if platelets rise about 50. ***Other transitional issues*** - OPAT Labs: For ceftriaxone, please check CBC with diff, BUN/Cr, LFTs weekly. For levofloxacin please check AST, ALT, TBili, ALK PHOS 7 days post discharge. ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] - He has continued on weekly IVIG 10mg q [MASKED] - Monitor QTc twice weekly while on levofloxacin and posaconazole - Please consider starting [MASKED] prophylaxis given CD4 count most recently of 53. A repeat CD4 count was pending at discharge. - He should continue to have weekly beta glucan testing for hx of invasive aspergillosis -Please check CBC, electrolyte panel, LFTs on [MASKED]. Fax results to [MASKED] clinic attention [MASKED] [MASKED]. - Discharge weight: 187.9 lbs # CODE: FULL CODE # EMERGENCY CONTACT: [MASKED] (wife, [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. copper gluconate 3 mg oral DAILY 4. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 5. Docusate Sodium 100 mg PO BID 6. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Simethicone 80 mg PO QID:PRN gas and bloating 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 11. Ursodiol 300 mg PO BID 12. Vitamin D [MASKED] UNIT PO DAILY 13. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 14. Lorazepam 0.5 mg PO QHS 15. Atovaquone Suspension 1500 mg PO DAILY 16. Diltiazem Extended-Release 360 mg PO DAILY 17. Furosemide 20 mg PO DAILY 18. Metoprolol Succinate XL 150 mg PO BID 19. PredniSONE 5 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. Budesonide 3 mg PO TID 22. FoLIC Acid 5 mg PO DAILY 23. Pantoprazole 40 mg PO Q24H 24. CeftriaXONE 2 gm IV Q24H Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. FoLIC Acid 5 mg PO DAILY 4. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. PredniSONE 5 mg PO DAILY 8. Simethicone 80 mg PO QID:PRN gas and bloating 9. Ursodiol 300 mg PO BID 10. Vitamin D [MASKED] UNIT PO DAILY 11. Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, TB, ALK PHOS CEFTRIAXONE: WEEKLY CBC with diff, BUN/Cr, LFTs weekly. 12. CeftriaXONE 2 gm IV Q24H 13. Diltiazem 60 mg PO Q6H 14. Metoprolol Tartrate 50 mg PO Q6H 15. Posaconazole Delayed Release Tablet 300 mg PO DAILY 16. Levofloxacin 750 mg PO DAILY 17. Enoxaparin Sodium 30 mg SC Q24H Start: [MASKED], First Dose: Next Routine Administration Time 18. Furosemide 80 mg PO DAILY 19. Acyclovir 400 mg PO Q8H Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS Health Care Associated Pneumonia PICC-associated partial deep vein thrombosis orthostatic hypotension SECONDARY DIAGNOSIS Atrial Fibrillation Acute Kidney Injury Myelodysplastic Syndrome Hypogammaglobulinemia 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 caring for you at [MASKED]. You came to the hospital because of concern for a pneumonia. We treated you with antibiotics and you improved. We did a procedure called a bronchoscopy and obtained a sample of your lung fluid, which showed bacterial infection. You will require continued antibiotics after discharge. You also had some low blood pressures while you were in the hospital. These improved when we decreased the doses of your diltiazem and metoprolol. We also found that you have a partial blood clot associated with your PICC. This will be monitored closely and you will be given a low dose of a blood thinner. Please let your doctor know if at any time you have worsening swelling or pain in the hand or arm, or if you have any bleeding at all. Important instructions: - Please participate with physical therapy every day. This is very important to regain your mobility and function. - Stay away from high salt foods as this will make you retain fluid - Continue taking antibiotics for your pneumonia - Continue all other medications as prescribed We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "Z87891", "I10", "K219", "Y92230", "G4733", "Y929" ]
[ "J156: Pneumonia due to other Gram-negative bacteria", "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "D89813: Graft-versus-host disease, unspecified", "D61811: Other drug-induced pancytopenia", "D4622: Refractory anemia with excess of blasts 2", "D801: Nonfamilial hypogammaglobulinemia", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82612: Acute embolism and thrombosis of superficial veins of left upper extremity", "T865: Complications of stem cell transplant", "I482: Chronic atrial fibrillation", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Y849: Medical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "I951: Orthostatic hypotension", "Z803: Family history of malignant neoplasm of breast", "K598: Other specified functional intestinal disorders", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "I340: Nonrheumatic mitral (valve) insufficiency", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "G4733: Obstructive sleep apnea (adult) (pediatric)", "T367X5A: Adverse effect of antifungal antibiotics, systemically used, initial encounter", "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" ]
10,064,049
28,193,514
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, tachycardia, thrombocytopenia. Major Surgical or Invasive Procedure: ___: ___ lung biopsy History of Present Illness: ___ hx of MDS ___ 2) presented in ___ with cytopenias and pneumonia with blasts. He is s/p bone marrow transplant ___ with reduced intensity conditioning from his brother. Course complicated by GVHD of gut with diarrhea--now resolved with tapering immunosuppression (Cyclosporin and prednisone 10 mg). Recently has had issues with afib with RVR and resultant HF. He has had decreased in platelets (usually 100's), now 50. He is slightly tachypneic. For these reasons, he presented from clinic to admission to ___. He states that for the past three days he has felt more short of breath and weak (trouble sitting up and increasing dyspnea on exertion and somewhat at rest). He is also endorsing some right knee pain which is worse with movement. He denies any chest tightness or pain, recent sick contact, cough, sore throat, headaches, visual changes (although he does endorse chronically itchy eyes). He denies any constipation or diarrhea, or difficulty urinating although he states that he has not been urinating that much with the Lasix. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: ___: C1 Decitabine ___: C2 Decitabine ___: C3 Decitabine ___: C4 Decitabine ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment ___: 99% donor **Bone marrow engraftment ___: 98% donor ***Peripheral engraftment ___: 99% donor ***Peripheral engraftment ___: 100% donor ***Peripheral engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem-->cefepime-->completing a 2 week course of outpatient cipro ADDITIONAL TREATMENT: ___: C1: IVIG ___: C2: IVIG ___: C3: IVIG ___: C4 IVIG ***Voriconazole stopped on ___ ***Posaconazole started on ___ PAST MEDICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD s/p EGD -s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: T 97.8 BP: 140/88 HR: 136 RR: 22 Sp02: 96% RA Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: JVP elevated to ear. LYMPH: No cervical or supraclav LAD CV: Irregularly, irregular. Tachcyardic Normal S1,S2. No MRG. LUNGS: Tachypneic, just barely able to finish a sentence. Fair air exchange, mild crackles in the bases. No wheezes or rhonchi. ABD: NABS. Soft, NT, slightly distended with dull flank. EXT: WWP. 2+ up to hips SKIN: Extensive senile purpura on arms with echymoses NEURO: A&Ox3. CN II-XII grossly intact. Sensation decreased in lower extremities secondary to wraps. LINES: PIV, non-erythematous or tender. ======================= DISCHARGE PHYSICAL EXAM ======================= Vitals: Tm 98.3F BP 100/72 P 70 RR 19 O2 96% RA Gen: Pleasant, calm, NAD. Comfortable-appearing. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Neck: No JVD. No cervical or supraclavicular LAD CV: Irregularly irregular. Normal S1, S2. No MRG. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Improving distension, soft, non-tender. No guarding, no rebound tenderness. NABS. Ext: WWP. 2+ edema in lower extremities. Neuro: A&Ox3. CN II-XII grossly intact. Decreased sensation in lower extremities. Lines: PICC dressing C/D/I Pertinent Results: ============== ADMISSION LABS ============== ___ 11:15AM BLOOD WBC-7.8 RBC-2.25* Hgb-8.2* Hct-24.6* MCV-109*# MCH-36.4* MCHC-33.3 RDW-20.5* RDWSD-80.1* Plt Ct-52* ___ 11:15AM BLOOD Neuts-93* Bands-0 Lymphs-1* Monos-5 Eos-0 Baso-0 ___ Myelos-1* NRBC-18* AbsNeut-7.25* AbsLymp-0.08* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* ___ 11:15AM BLOOD Plt Smr-VERY LOW Plt Ct-52* ___ 11:15AM BLOOD ___ PTT-35.5 ___ ___ 11:15AM BLOOD UreaN-63* Creat-1.6* Na-138 K-3.1* Cl-102 HCO3-24 AnGap-15 ___ 11:15AM BLOOD Glucose-144* ___ 11:15AM BLOOD ALT-64* AST-42* LD(LDH)-685* AlkPhos-262* TotBili-0.8 ___ 11:15AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.7 UricAcd-8.2* ___ 11:15AM BLOOD ___ Ferritn-5626* ============ INTERIM LABS ============ ___ 05:55AM BLOOD WBC-8.8 RBC-1.87* Hgb-7.3* Hct-21.6* MCV-116* MCH-39.0* MCHC-33.8 RDW-24.9* RDWSD-101.4* Plt Ct-63* ___ 12:05AM BLOOD WBC-2.4* RBC-1.96* Hgb-7.3* Hct-22.7* MCV-116* MCH-37.2* MCHC-32.2 RDW-27.6* RDWSD-111.0* Plt Ct-78* ___ 12:00AM BLOOD WBC-3.8* RBC-2.11* Hgb-7.8* Hct-24.9* MCV-118* MCH-37.0* MCHC-31.3* RDW-25.4* RDWSD-104.5* Plt Ct-42* ___ 05:55AM BLOOD Neuts-89* Bands-0 Lymphs-2* Monos-8 Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-6* AbsNeut-7.83* AbsLymp-0.18* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00* ___ 10:35AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-3* Eos-0* Baso-0 ___ Myelos-0 AbsNeut-2.91 AbsLymp-0.09* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Neuts-79* Bands-2 Lymphs-6* Monos-13 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.16 AbsLymp-0.23* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD ___ 12:09AM BLOOD Ret Aut-4.5* Abs Ret-0.08 ___ 06:05AM BLOOD Glucose-78 UreaN-37* Creat-1.3* Na-125* K-3.9 Cl-91* HCO3-24 AnGap-14 ___ 12:05AM BLOOD Glucose-81 UreaN-26* Creat-1.3* Na-130* K-4.1 Cl-99 HCO3-22 AnGap-13 ___ 12:00AM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-133 K-3.3 Cl-93* HCO3-27 AnGap-16 ___ 06:05AM BLOOD ALT-53* AST-40 LD(___)-658* AlkPhos-289* TotBili-1.0 ___ 12:00AM BLOOD ALT-197* AST-92* LD(___)-352* AlkPhos-237* TotBili-0.3 ___ 12:00AM BLOOD ALT-62* AST-27 LD(LDH)-330* AlkPhos-230* Amylase-37 TotBili-0.8 ___ 06:05AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.7 UricAcd-5.6 ___ 12:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.3* Mg-1.9 ___ 12:00AM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.3 Mg-2.1 UricAcd-6.8 ___ 05:35PM BLOOD Osmolal-272* ___ 09:00PM BLOOD Osmolal-268* ___ 03:00PM BLOOD Osmolal-277 ___ 06:05AM BLOOD Osmolal-267* ___ 04:09AM BLOOD TSH-1.4 ___ 12:32AM BLOOD Cortsol-11.3 ___ 05:55PM BLOOD Lactate-1.7 ___ 10:36AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG ___ 10:36AM URINE Hours-RANDOM Creat-43 Na-144 K-21 Cl-116 Uric Ac-36.9 ___ 09:00PM URINE Hours-RANDOM Creat-49 Na-138 K-26 Cl-115 Uric Ac-38.5 ___ 05:12PM URINE Hours-RANDOM Na-151 K-18 Cl-152 ___ 03:45PM URINE Hours-RANDOM Na-135 K-31 Cl-150 ___ 03:00PM URINE Hours-RANDOM Creat-23 Na-162 K-29 Cl-179 Uric Ac-17.4 ___ 10:36AM URINE Osmolal-471 ___ 09:00PM URINE Osmolal-493 ___ 05:12PM URINE Osmolal-436 ___ 10:11PM URINE Osmolal-566 ============== DISCHARGE LABS ============== ___ 12:00AM BLOOD WBC-4.2 RBC-2.33* Hgb-8.4* Hct-25.6* MCV-110*# MCH-36.1* MCHC-32.8 RDW-27.1* RDWSD-101.8* Plt Ct-91* ___ 12:00AM BLOOD Neuts-79* Bands-2 Lymphs-5* Monos-11 Eos-0 Baso-0 ___ Metas-1* Myelos-1* Promyel-1* NRBC-1* AbsNeut-3.40 AbsLymp-0.21* AbsMono-0.46 AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL ___ 12:00AM BLOOD Plt Smr-LOW Plt Ct-91* ___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-131* UreaN-30* Creat-1.0 Na-136 K-3.8 Cl-101 HCO3-24 AnGap-15 ___ 12:00AM BLOOD ALT-59* AST-42* LD(LDH)-339* AlkPhos-286* TotBili-0.4 ___ 12:00AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.1 Mg-1.9 =============== IMAGING/STUDIES =============== ___: CT CHEST W/O CONTRAST FINDINGS: MEDIASTINUM: The imaged thyroid is normal. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. A partially calcified left hilar lymph node is unchanged. The aorta is mildly ectatic measuring 4 cm and pulmonary arteries are normal in size. The heart size is mildly enlarged and there is no pericardial effusion. Left-sided PICC terminates in the low SVC. PLEURA: There is no pneumothorax. Small bilateral nonhemorrhagic pleural effusions, have decreased. LUNGS: The airways are patent. Rounded opacity in the right lower lobe Has slightly decreased in size measuring 24 x 22 mm previously 27 x 29 mm. The surrounding ground-glass halo around the opacity has also decreased locally. There is new ground-glass and nodular opacity in the posterior segment of the right lower lobe series 5, image 245. Peribronchial opacities in the left lower lobe and right middle lobe have also improved. Diffuse bronchial wall thickening has progressed. Multiple scattered granulomas throughout the lungs. BONES: There are no destructive focal osseous lesions concerning for malignancy within the imaged thoracic skeleton. UPPER ABDOMEN: This study is not tailored to evaluate the abdomen. The esophagus is mildly patulous. Multiple punctate calcifications in the spleen are consistent with prior granulomatous infection. Otherwise the imaged upper abdominal structures are grossly unremarkable. IMPRESSION: Slight interval decrease in the right lower lobe nodular opacity, biopsy-proven Nocardia as well as bilateral small effusions. New consolidation in the dependent portion of the right lower lobe likely aspiration given the patulous esophagus, rather than spread of Nocardia. ___: ABDOMEN (SUPINE & ERECT FINDINGS: There are air-filled and abnormally enlarged loops of transverse colon measuring up to 7 cm, new since comparison study. There are air filled and non-dilated loops of small bowel. There is no free intraperitoneal air. There are punctate radiopaque foci overlying the left upper quadrant which corresponds to splenic calcifications seen on comparison study. IMPRESSION: 1. Dilated transverse colon most compatible with a focal colonic ileus. ___: CT ABD & PELVIS WITH CO IMPRESSION: 1. No colonic or small bowel wall thickening to suggest colitis or graft versus host disease. Fluid-filled loops of colon may account for abdominal distention. 2. Small amount of perihepatic free fluid. 3. Stable masslike consolidation at the right lung base as seen in ___, representing biopsy-proven Nocardia infection. 4. Evidence of prior granulomatous exposure. ___: UNILAT LOWER EXT VEINS FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. ___: MR HEAD W & W/O CONTRAS FINDINGS: Study is mildly degraded by motion. There is no evidence of hemorrhage, mass, infarct, edema, or midline shift. There is prominence of the ventricles and sulci suggestive involutional changes. There is no enhancing lesion of on post contrast sequences. Periventricular and subcortical T2 and FLAIR hyperintensities are noted, which may represent small vessel ischemic changes. Minimal mucosal thickening involves the bilateral maxillary sinuses, right greater than left, as well as left anterior ethmoidal air cells. There is minimal bilateral mastoid air cell fluid. Intracranial flow voids are preserved. Dural sinuses are patent. IMPRESSION: 1. Study is mildly degraded by motion. 2. Probable small vessel ischemic changes as described. 3. No acute intracranial abnormality. 4. Minimal paranasal sinus disease and small nonspecific mastoid fluid as described. ___: CXR (AP): FINDINGS: No significant changes compared to prior exam. The patient is status post right lung biopsy. Postsurgical changes are seen at the right lung base. Stable calcified granuloma in the left lung base. Small bilateral pleural effusions can't be excluded. Enlarged heart size is unchanged. There is no pneumothorax. IMPRESSION: No evidence of pneumothorax. ___: CXR (PA/LAT) FINDINGS: A 2.6 cm rounded opacity is seen in the right lower lung. Increased opacity in the right lower lung abutting the right heart border is concerning for consolidation. Increased heart size may indicate cardiomegaly and/or pericardial effusion. Small pleural effusions are new. A 6 mm calcified granuloma in the left lower lung is stable. A 1.2 cm calcified lymph node is seen on the lateral view. No pneumothorax is seen. The hilar and mediastinal silhouettes are unremarkable. IMPRESSION: 1. New infectious nodule, R lower lung 2. Opacity in the right lung base is concerning for consolidation. 3. Increased heart size may indicate cardiomegaly and/or pericardial effusion. 4. Small pleural effusions are new. ___: KNEE (AP, LAT AND OBLIQUE) RIGHT The bony structures and joint spaces are essentially within normal limits with no evidence of erosive change or definite joint effusion. ___: CT CHEST W/O CONTRAST 1. New mass-like consolidation with ground-glass halo concerning for angioinvasive aspergillus infection in this patient with immunosuppression. Given the rapid development of this consolidation infection is favored over malignancy. 2.Previously seen multifocal ground-glass and nodular opacities, most pronounced in the lingula have resolved. ============ MICROBIOLOGY ============ __________________________________________________________ ___ 12:00 am Immunology (CMV) Source: Line-PICC. **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. __________________________________________________________ ___ 9:56 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). TEST REQUESTED BY ___ ___. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. __________________________________________________________ ___ 1:08 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: CANCELLED. Test cancelled. Only one C. difficile test will normally be performed per week. If clinically indicated, please resubmit a new specimen after a 7 day or greater interval has elapsed. Note, if there are compelling clinical reasons for repeat testing within a seven day window (see discussion in ___ laboratory manual), page the clinical microbiology resident on call (pager ___ to discuss the need for this repeat testing. FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. 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. __________________________________________________________ ___ 10:36 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:41 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 12:55 pm TISSUE Site: LUNG RIGHT LOWER CONSOLIDATION. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: Reported to and read back by ___. ___ ___. NOCARDIA NOVA. SPARSE GROWTH. IDENTIFIED AT ___. SENT TO ___ FOR SUSCEPTIBILITY TESTING Refer to sendout/miscellaneous reporting for results. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. NOCARDIA NOVA. IDENTIFIED AT ___. NOCARDIA CULTURE (Final ___: NOCARDIA NOVA. IDENTIFICATION PERFORMED AT ___. ========= PATHOLOGY ========= LUNG, CORE BIOPSY FOR TUMOR (___): Lung, right lower lobe biopsy: Alveolar tissue with necrosis and fibropurulent exudate, see note. Note: GMS, B and B and ___ stains show organisms morphologically consistent with nocardia. AFB stains are negative. Immunophenotyping- Lung (___): INTERPRETATION: Nondiagnostic study. B cells were scant precluding evaluation of clonality. Correlation with clinical findings and morphology (see separate pathology report ___ is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. BONE MARROW, BIOPSY, CORE (___): DIAGNOSIS: VARIABLY CELLULAR BONE MARROW WITH TRILINEAGE DYSPOIETIC MATURATION. THESE FINDINGS RAISE THE POSSIBILITY OF RELAPSING MYELODYSPLASTIC SYNDROME. SEE NOTE. Note: The presence of significant trilineage dyspoiesis in the post-transplant setting may be indicative of relapsing myelodysplastic syndrome. Nevertheless, interccurent viral infections, such as CMV infection, and medication effect, which can cause similar morphological dyspoiesis, need to be ruled out. By immunohistochemistry, CD34 highlights less than 5% blasts. Please correlate with cytogenetic and chimerism studies. Brief Hospital Course: ___ is a ___ year old man with MDS RAEB Type 2 with allogeneic related donor and atrial fibrillation with RVR who presented with three days of tachypnea and volume overload likely secondary to atrial fibrillation, as well as bone marrow findings concerning for MDS relapse. # Pulmonary Nocardiosis. ___ was found to have a right upper lobe lung consolidation on CT, which was initially concerning for angioinvasive aspergillosis (he had been on posaconazole prophylaxis for a history of aspergillosis). B-glucan was positive; galactomannan was negative. The nodule was biopsied on ___, and it was found to be Nocardia nova. He was initially treated with imipenem/Bactrim, however he subsequently developed SIADH and diarrhea with this, so he was switched to imipenem/minocycline. He will have a minimum six week course, ending tentatively ___. Repeat CT demonstrated interval improvement in the size of the mass. # Atrial fibrillation with rapid ventricular response. This was previously well-controlled on diltiazem and metoprolol. Initially had been planned for TEE/cardioversion (for which he had been anti-coagulated with warfarin). INR was 4.8 on admission and was reversed with vitamin K prior to his biopsy. He was rate controlled with higher doses of his home medications and was discharged on metoprolol succinate 150 mg bid and diltiazem XL 360 mg daily. This atrial fibrillation also contributed to significant volume overload, for which he was actively diuresed with 40 mg IV Lasix. He was transitioned to PO Lasix 20 mg daily (home dose) to a dry weight of 175.1 lbs. # Myelodysplastic syndrome. Type 2, refractory anemia with excess blasts, s/p matched, related donor allogenic transplant (day +377 on ___ with reduced intensity conditioning. Bone marrow biopsy was obtained, which demonstrated concern for relapsed MDS. ___ chimerism/engraftment studies were sent the day prior to discharge. Was treated supportively and received three units of pRBCs during his hospitalization. # SIADH. Was hyponatremic to 125 in the setting of initiating Bactrim. Free water challenge test was performed with elevated urine osmolality, which confirmed SIADH. # Right knee pain. Endorsed three days of right knee pain prior to admission. Plain film demonstrated no fracture or effusion. Pain improved with diuresis. =================== TRANSITIONAL ISSUES =================== # Antibiotic course: Will be discharged with imipenem 500 mg q6h and minocycline 200 mg PO BID for a course ending tentatively ___, at which point he will be re-imaged. Will require weekly CBC w/ differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS. All lab results should be sent to: ATTN: ___ CLINIC - FAX: ___. Will have outpatient ID follow-up. # Immunosuppression. Cyclosporine discontinued. Prednisone decreased to 7.5 mg daily. # Atrial fibrillation. Will be discharged on metoprolol succinate 150 mg bid, and diltiazem XL 360 mg daily. Anticoagulation was halted given CHA2DS2-Vasc score of 2. # Discharge weight: 175.1 lbs # Code status: FULL # Contact: ___, wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Atovaquone Suspension 750 mg PO DAILY 3. Budesonide 3 mg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 5. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 6. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 7. Diltiazem Extended-Release 240 mg PO DAILY 8. FoLIC Acid 1 mg PO FIVE TIMES DAILY 9. Furosemide 20 mg PO DAILY 10. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 11. Lorazepam 0.5 mg PO QHS 12. Metoprolol Succinate XL 50 mg PO DAILY 13. Pantoprazole 40 mg PO Q12H 14. Posaconazole Delayed Release Tablet 100 mg PO TID 15. Potassium Chloride 20 mEq PO DAILY 16. PredniSONE 10 mg PO DAILY 17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 18. Ursodiol 300 mg PO BID 19. Warfarin Dose is Unknown PO Frequency is Unknown 20. Vitamin D ___ UNIT PO DAILY 21. copper gluconate 2 mg oral DAILY 22. Magnesium Oxide 400 mg PO BID 23. Multivitamins 1 TAB PO DAILY 24. Bisacodyl 10 mg PO DAILY:PRN constipation 25. Docusate Sodium 100 mg PO BID 26. Oxymetazoline 1 SPRY NU Frequency is Unknown 27. Simethicone 80 mg PO QID:PRN gas and bloating Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. copper gluconate 3 mg oral DAILY 4. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 5. Docusate Sodium 100 mg PO BID 6. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Simethicone 80 mg PO QID:PRN gas and bloating 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 11. Ursodiol 300 mg PO BID 12. Vitamin D ___ UNIT PO DAILY 13. Imipenem-Cilastatin 500 mg IV Q6H 14. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 15. Lorazepam 0.5 mg PO QHS 16. Atovaquone Suspension 1500 mg PO DAILY 17. Diltiazem Extended-Release 360 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. Metoprolol Succinate XL 150 mg PO BID 20. Posaconazole Delayed Release Tablet 100 mg PO TID 21. PredniSONE 7.5 mg PO DAILY 22. Minocycline 200 mg PO BID 23. Magnesium Oxide 400 mg PO BID 24. Outpatient Lab Work Diagnosis: Pulmonary Nocardiosis (ICD-10: A43.0) Please check weekly: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ 25. Budesonide 3 mg PO TID 26. FoLIC Acid 5 mg PO DAILY 27. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Discharge Diagnosis: ================= PRIMARY DIAGNOSES ================= - myelodysplastic syndrome, type 2 (refractory anemia with excess blasts) - pulmonary Nocardiosis - atrial fibrillation with rapid ventricular response =================== SECONDARY DIAGNOSES =================== - obstructive sleep apnea - history of aspergillosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, It was a pleasure caring for you at ___ ___. You were admitted for shortness of breath, increased swelling in your legs, and rapid heart rate. While you were here, we controlled your heart rate with metoprolol and diltiazem. You were also found to have an infection in your lung, which was biopsied and demonstrated a bacteria called "Nocardia." You have been started on an extended course of antibiotics for this infection. We gave you a medication called Lasix to remove fluid from your body and decrease the swelling in your legs. You also developed a significant diarrhea, which we think was related to one of the antibiotics that we stopped. You will be going to a rehabilitation facility to continue your recovery. Please continue to take all medications as prescribed. We wish you the very best! Warmly, Your ___ Team Followup Instructions: ___
[ "A430", "D4622", "E222", "Z9484", "E8770", "I480", "G4733", "Z7901", "Z87891", "I10", "K219", "R197", "Z85828", "Z801", "Z803", "T370X5A", "M25561" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Shortness of breath, tachycardia, thrombocytopenia. Major Surgical or Invasive Procedure: [MASKED]: [MASKED] lung biopsy History of Present Illness: [MASKED] hx of MDS [MASKED] 2) presented in [MASKED] with cytopenias and pneumonia with blasts. He is s/p bone marrow transplant [MASKED] with reduced intensity conditioning from his brother. Course complicated by GVHD of gut with diarrhea--now resolved with tapering immunosuppression (Cyclosporin and prednisone 10 mg). Recently has had issues with afib with RVR and resultant HF. He has had decreased in platelets (usually 100's), now 50. He is slightly tachypneic. For these reasons, he presented from clinic to admission to [MASKED]. He states that for the past three days he has felt more short of breath and weak (trouble sitting up and increasing dyspnea on exertion and somewhat at rest). He is also endorsing some right knee pain which is worse with movement. He denies any chest tightness or pain, recent sick contact, cough, sore throat, headaches, visual changes (although he does endorse chronically itchy eyes). He denies any constipation or diarrhea, or difficulty urinating although he states that he has not been urinating that much with the Lasix. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): BONE MARROW BIOPSY [MASKED]: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS [MASKED]: 45X -Y, Negative for common abnormality seen in MDS. [MASKED] for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY [MASKED]: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS [MASKED]: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW [MASKED]: Prelim results show 7% blasts TREATMENT HISTORY: [MASKED]: C1 Decitabine [MASKED]: C2 Decitabine [MASKED]: C3 Decitabine [MASKED]: C4 Decitabine [MASKED]: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut **Peripheral engraftment [MASKED]: 99% donor **Bone marrow engraftment [MASKED]: 98% donor ***Peripheral engraftment [MASKED]: 99% donor ***Peripheral engraftment [MASKED]: 100% donor ***Peripheral engraftment [MASKED]: 100% donor Other events: --[MASKED]: Admitted for GVHD of the gut --[MASKED]: Admitted, found to have stenotrophomonas and aspergillus in BAL --[MASKED]: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --[MASKED]: Started on posaconazole for fungal prophylaxis --[MASKED]: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem-->cefepime-->completing a 2 week course of outpatient cipro ADDITIONAL TREATMENT: [MASKED]: C1: IVIG [MASKED]: C2: IVIG [MASKED]: C3: IVIG [MASKED]: C4 IVIG ***Voriconazole stopped on [MASKED] ***Posaconazole started on [MASKED] PAST MEDICAL HISTORY: -pAtrial fibrillation with RVR -HTN -Basal cell carcinoma -Sleep apnea on CPAP -GERD s/p EGD -s/p inguinal hernia repair w/ mesh Social History: [MASKED] Family History: - Mother: alive at [MASKED] - Father: deceased at [MASKED] from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: T 97.8 BP: 140/88 HR: 136 RR: 22 Sp02: 96% RA Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: JVP elevated to ear. LYMPH: No cervical or supraclav LAD CV: Irregularly, irregular. Tachcyardic Normal S1,S2. No MRG. LUNGS: Tachypneic, just barely able to finish a sentence. Fair air exchange, mild crackles in the bases. No wheezes or rhonchi. ABD: NABS. Soft, NT, slightly distended with dull flank. EXT: WWP. 2+ up to hips SKIN: Extensive senile purpura on arms with echymoses NEURO: A&Ox3. CN II-XII grossly intact. Sensation decreased in lower extremities secondary to wraps. LINES: PIV, non-erythematous or tender. ======================= DISCHARGE PHYSICAL EXAM ======================= Vitals: Tm 98.3F BP 100/72 P 70 RR 19 O2 96% RA Gen: Pleasant, calm, NAD. Comfortable-appearing. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Neck: No JVD. No cervical or supraclavicular LAD CV: Irregularly irregular. Normal S1, S2. No MRG. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Improving distension, soft, non-tender. No guarding, no rebound tenderness. NABS. Ext: WWP. 2+ edema in lower extremities. Neuro: A&Ox3. CN II-XII grossly intact. Decreased sensation in lower extremities. Lines: PICC dressing C/D/I Pertinent Results: ============== ADMISSION LABS ============== [MASKED] 11:15AM BLOOD WBC-7.8 RBC-2.25* Hgb-8.2* Hct-24.6* MCV-109*# MCH-36.4* MCHC-33.3 RDW-20.5* RDWSD-80.1* Plt Ct-52* [MASKED] 11:15AM BLOOD Neuts-93* Bands-0 Lymphs-1* Monos-5 Eos-0 Baso-0 [MASKED] Myelos-1* NRBC-18* AbsNeut-7.25* AbsLymp-0.08* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* [MASKED] 11:15AM BLOOD Plt Smr-VERY LOW Plt Ct-52* [MASKED] 11:15AM BLOOD [MASKED] PTT-35.5 [MASKED] [MASKED] 11:15AM BLOOD UreaN-63* Creat-1.6* Na-138 K-3.1* Cl-102 HCO3-24 AnGap-15 [MASKED] 11:15AM BLOOD Glucose-144* [MASKED] 11:15AM BLOOD ALT-64* AST-42* LD(LDH)-685* AlkPhos-262* TotBili-0.8 [MASKED] 11:15AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.7 UricAcd-8.2* [MASKED] 11:15AM BLOOD [MASKED] Ferritn-5626* ============ INTERIM LABS ============ [MASKED] 05:55AM BLOOD WBC-8.8 RBC-1.87* Hgb-7.3* Hct-21.6* MCV-116* MCH-39.0* MCHC-33.8 RDW-24.9* RDWSD-101.4* Plt Ct-63* [MASKED] 12:05AM BLOOD WBC-2.4* RBC-1.96* Hgb-7.3* Hct-22.7* MCV-116* MCH-37.2* MCHC-32.2 RDW-27.6* RDWSD-111.0* Plt Ct-78* [MASKED] 12:00AM BLOOD WBC-3.8* RBC-2.11* Hgb-7.8* Hct-24.9* MCV-118* MCH-37.0* MCHC-31.3* RDW-25.4* RDWSD-104.5* Plt Ct-42* [MASKED] 05:55AM BLOOD Neuts-89* Bands-0 Lymphs-2* Monos-8 Eos-0 Baso-0 [MASKED] Metas-1* Myelos-0 NRBC-6* AbsNeut-7.83* AbsLymp-0.18* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00* [MASKED] 10:35AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-3* Eos-0* Baso-0 [MASKED] Myelos-0 AbsNeut-2.91 AbsLymp-0.09* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Neuts-79* Bands-2 Lymphs-6* Monos-13 Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-3.16 AbsLymp-0.23* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD [MASKED] 12:09AM BLOOD Ret Aut-4.5* Abs Ret-0.08 [MASKED] 06:05AM BLOOD Glucose-78 UreaN-37* Creat-1.3* Na-125* K-3.9 Cl-91* HCO3-24 AnGap-14 [MASKED] 12:05AM BLOOD Glucose-81 UreaN-26* Creat-1.3* Na-130* K-4.1 Cl-99 HCO3-22 AnGap-13 [MASKED] 12:00AM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-133 K-3.3 Cl-93* HCO3-27 AnGap-16 [MASKED] 06:05AM BLOOD ALT-53* AST-40 LD([MASKED])-658* AlkPhos-289* TotBili-1.0 [MASKED] 12:00AM BLOOD ALT-197* AST-92* LD([MASKED])-352* AlkPhos-237* TotBili-0.3 [MASKED] 12:00AM BLOOD ALT-62* AST-27 LD(LDH)-330* AlkPhos-230* Amylase-37 TotBili-0.8 [MASKED] 06:05AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.7 UricAcd-5.6 [MASKED] 12:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.3* Mg-1.9 [MASKED] 12:00AM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.3 Mg-2.1 UricAcd-6.8 [MASKED] 05:35PM BLOOD Osmolal-272* [MASKED] 09:00PM BLOOD Osmolal-268* [MASKED] 03:00PM BLOOD Osmolal-277 [MASKED] 06:05AM BLOOD Osmolal-267* [MASKED] 04:09AM BLOOD TSH-1.4 [MASKED] 12:32AM BLOOD Cortsol-11.3 [MASKED] 05:55PM BLOOD Lactate-1.7 [MASKED] 10:36AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG [MASKED] 10:36AM URINE Hours-RANDOM Creat-43 Na-144 K-21 Cl-116 Uric Ac-36.9 [MASKED] 09:00PM URINE Hours-RANDOM Creat-49 Na-138 K-26 Cl-115 Uric Ac-38.5 [MASKED] 05:12PM URINE Hours-RANDOM Na-151 K-18 Cl-152 [MASKED] 03:45PM URINE Hours-RANDOM Na-135 K-31 Cl-150 [MASKED] 03:00PM URINE Hours-RANDOM Creat-23 Na-162 K-29 Cl-179 Uric Ac-17.4 [MASKED] 10:36AM URINE Osmolal-471 [MASKED] 09:00PM URINE Osmolal-493 [MASKED] 05:12PM URINE Osmolal-436 [MASKED] 10:11PM URINE Osmolal-566 ============== DISCHARGE LABS ============== [MASKED] 12:00AM BLOOD WBC-4.2 RBC-2.33* Hgb-8.4* Hct-25.6* MCV-110*# MCH-36.1* MCHC-32.8 RDW-27.1* RDWSD-101.8* Plt Ct-91* [MASKED] 12:00AM BLOOD Neuts-79* Bands-2 Lymphs-5* Monos-11 Eos-0 Baso-0 [MASKED] Metas-1* Myelos-1* Promyel-1* NRBC-1* AbsNeut-3.40 AbsLymp-0.21* AbsMono-0.46 AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL [MASKED] 12:00AM BLOOD Plt Smr-LOW Plt Ct-91* [MASKED] 12:00AM BLOOD [MASKED] 12:00AM BLOOD Glucose-131* UreaN-30* Creat-1.0 Na-136 K-3.8 Cl-101 HCO3-24 AnGap-15 [MASKED] 12:00AM BLOOD ALT-59* AST-42* LD(LDH)-339* AlkPhos-286* TotBili-0.4 [MASKED] 12:00AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.1 Mg-1.9 =============== IMAGING/STUDIES =============== [MASKED]: CT CHEST W/O CONTRAST FINDINGS: MEDIASTINUM: The imaged thyroid is normal. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. A partially calcified left hilar lymph node is unchanged. The aorta is mildly ectatic measuring 4 cm and pulmonary arteries are normal in size. The heart size is mildly enlarged and there is no pericardial effusion. Left-sided PICC terminates in the low SVC. PLEURA: There is no pneumothorax. Small bilateral nonhemorrhagic pleural effusions, have decreased. LUNGS: The airways are patent. Rounded opacity in the right lower lobe Has slightly decreased in size measuring 24 x 22 mm previously 27 x 29 mm. The surrounding ground-glass halo around the opacity has also decreased locally. There is new ground-glass and nodular opacity in the posterior segment of the right lower lobe series 5, image 245. Peribronchial opacities in the left lower lobe and right middle lobe have also improved. Diffuse bronchial wall thickening has progressed. Multiple scattered granulomas throughout the lungs. BONES: There are no destructive focal osseous lesions concerning for malignancy within the imaged thoracic skeleton. UPPER ABDOMEN: This study is not tailored to evaluate the abdomen. The esophagus is mildly patulous. Multiple punctate calcifications in the spleen are consistent with prior granulomatous infection. Otherwise the imaged upper abdominal structures are grossly unremarkable. IMPRESSION: Slight interval decrease in the right lower lobe nodular opacity, biopsy-proven Nocardia as well as bilateral small effusions. New consolidation in the dependent portion of the right lower lobe likely aspiration given the patulous esophagus, rather than spread of Nocardia. [MASKED]: ABDOMEN (SUPINE & ERECT FINDINGS: There are air-filled and abnormally enlarged loops of transverse colon measuring up to 7 cm, new since comparison study. There are air filled and non-dilated loops of small bowel. There is no free intraperitoneal air. There are punctate radiopaque foci overlying the left upper quadrant which corresponds to splenic calcifications seen on comparison study. IMPRESSION: 1. Dilated transverse colon most compatible with a focal colonic ileus. [MASKED]: CT ABD & PELVIS WITH CO IMPRESSION: 1. No colonic or small bowel wall thickening to suggest colitis or graft versus host disease. Fluid-filled loops of colon may account for abdominal distention. 2. Small amount of perihepatic free fluid. 3. Stable masslike consolidation at the right lung base as seen in [MASKED], representing biopsy-proven Nocardia infection. 4. Evidence of prior granulomatous exposure. [MASKED]: UNILAT LOWER EXT VEINS FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. [MASKED]: MR HEAD W & W/O CONTRAS FINDINGS: Study is mildly degraded by motion. There is no evidence of hemorrhage, mass, infarct, edema, or midline shift. There is prominence of the ventricles and sulci suggestive involutional changes. There is no enhancing lesion of on post contrast sequences. Periventricular and subcortical T2 and FLAIR hyperintensities are noted, which may represent small vessel ischemic changes. Minimal mucosal thickening involves the bilateral maxillary sinuses, right greater than left, as well as left anterior ethmoidal air cells. There is minimal bilateral mastoid air cell fluid. Intracranial flow voids are preserved. Dural sinuses are patent. IMPRESSION: 1. Study is mildly degraded by motion. 2. Probable small vessel ischemic changes as described. 3. No acute intracranial abnormality. 4. Minimal paranasal sinus disease and small nonspecific mastoid fluid as described. [MASKED]: CXR (AP): FINDINGS: No significant changes compared to prior exam. The patient is status post right lung biopsy. Postsurgical changes are seen at the right lung base. Stable calcified granuloma in the left lung base. Small bilateral pleural effusions can't be excluded. Enlarged heart size is unchanged. There is no pneumothorax. IMPRESSION: No evidence of pneumothorax. [MASKED]: CXR (PA/LAT) FINDINGS: A 2.6 cm rounded opacity is seen in the right lower lung. Increased opacity in the right lower lung abutting the right heart border is concerning for consolidation. Increased heart size may indicate cardiomegaly and/or pericardial effusion. Small pleural effusions are new. A 6 mm calcified granuloma in the left lower lung is stable. A 1.2 cm calcified lymph node is seen on the lateral view. No pneumothorax is seen. The hilar and mediastinal silhouettes are unremarkable. IMPRESSION: 1. New infectious nodule, R lower lung 2. Opacity in the right lung base is concerning for consolidation. 3. Increased heart size may indicate cardiomegaly and/or pericardial effusion. 4. Small pleural effusions are new. [MASKED]: KNEE (AP, LAT AND OBLIQUE) RIGHT The bony structures and joint spaces are essentially within normal limits with no evidence of erosive change or definite joint effusion. [MASKED]: CT CHEST W/O CONTRAST 1. New mass-like consolidation with ground-glass halo concerning for angioinvasive aspergillus infection in this patient with immunosuppression. Given the rapid development of this consolidation infection is favored over malignancy. 2.Previously seen multifocal ground-glass and nodular opacities, most pronounced in the lingula have resolved. ============ MICROBIOLOGY ============ [MASKED] [MASKED] 12:00 am Immunology (CMV) Source: Line-PICC. **FINAL REPORT [MASKED] CMV Viral Load (Final [MASKED]: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the [MASKED] patient population. [MASKED] [MASKED] 9:56 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] CYCLOSPORA STAIN (Final [MASKED]: NO CYCLOSPORA SEEN. MICROSPORIDIA STAIN (Final [MASKED]: NO MICROSPORIDIUM SEEN. C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). TEST REQUESTED BY [MASKED] [MASKED]. Cryptosporidium/Giardia (DFA) (Final [MASKED]: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. [MASKED] [MASKED] 1:08 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: CANCELLED. Test cancelled. Only one C. difficile test will normally be performed per week. If clinically indicated, please resubmit a new specimen after a 7 day or greater interval has elapsed. Note, if there are compelling clinical reasons for repeat testing within a seven day window (see discussion in [MASKED] laboratory manual), page the clinical microbiology resident on call (pager [MASKED] to discuss the need for this repeat testing. FECAL CULTURE (Final [MASKED]: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. 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] [MASKED] 10:36 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:41 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 12:55 pm TISSUE Site: LUNG RIGHT LOWER CONSOLIDATION. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [MASKED]: Reported to and read back by [MASKED]. [MASKED] [MASKED]. NOCARDIA NOVA. SPARSE GROWTH. IDENTIFIED AT [MASKED]. SENT TO [MASKED] FOR SUSCEPTIBILITY TESTING Refer to sendout/miscellaneous reporting for results. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [MASKED]: NO FUNGUS ISOLATED. NOCARDIA NOVA. IDENTIFIED AT [MASKED]. NOCARDIA CULTURE (Final [MASKED]: NOCARDIA NOVA. IDENTIFICATION PERFORMED AT [MASKED]. ========= PATHOLOGY ========= LUNG, CORE BIOPSY FOR TUMOR ([MASKED]): Lung, right lower lobe biopsy: Alveolar tissue with necrosis and fibropurulent exudate, see note. Note: GMS, B and B and [MASKED] stains show organisms morphologically consistent with nocardia. AFB stains are negative. Immunophenotyping- Lung ([MASKED]): INTERPRETATION: Nondiagnostic study. B cells were scant precluding evaluation of clonality. Correlation with clinical findings and morphology (see separate pathology report [MASKED] is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. BONE MARROW, BIOPSY, CORE ([MASKED]): DIAGNOSIS: VARIABLY CELLULAR BONE MARROW WITH TRILINEAGE DYSPOIETIC MATURATION. THESE FINDINGS RAISE THE POSSIBILITY OF RELAPSING MYELODYSPLASTIC SYNDROME. SEE NOTE. Note: The presence of significant trilineage dyspoiesis in the post-transplant setting may be indicative of relapsing myelodysplastic syndrome. Nevertheless, interccurent viral infections, such as CMV infection, and medication effect, which can cause similar morphological dyspoiesis, need to be ruled out. By immunohistochemistry, CD34 highlights less than 5% blasts. Please correlate with cytogenetic and chimerism studies. Brief Hospital Course: [MASKED] is a [MASKED] year old man with MDS RAEB Type 2 with allogeneic related donor and atrial fibrillation with RVR who presented with three days of tachypnea and volume overload likely secondary to atrial fibrillation, as well as bone marrow findings concerning for MDS relapse. # Pulmonary Nocardiosis. [MASKED] was found to have a right upper lobe lung consolidation on CT, which was initially concerning for angioinvasive aspergillosis (he had been on posaconazole prophylaxis for a history of aspergillosis). B-glucan was positive; galactomannan was negative. The nodule was biopsied on [MASKED], and it was found to be Nocardia nova. He was initially treated with imipenem/Bactrim, however he subsequently developed SIADH and diarrhea with this, so he was switched to imipenem/minocycline. He will have a minimum six week course, ending tentatively [MASKED]. Repeat CT demonstrated interval improvement in the size of the mass. # Atrial fibrillation with rapid ventricular response. This was previously well-controlled on diltiazem and metoprolol. Initially had been planned for TEE/cardioversion (for which he had been anti-coagulated with warfarin). INR was 4.8 on admission and was reversed with vitamin K prior to his biopsy. He was rate controlled with higher doses of his home medications and was discharged on metoprolol succinate 150 mg bid and diltiazem XL 360 mg daily. This atrial fibrillation also contributed to significant volume overload, for which he was actively diuresed with 40 mg IV Lasix. He was transitioned to PO Lasix 20 mg daily (home dose) to a dry weight of 175.1 lbs. # Myelodysplastic syndrome. Type 2, refractory anemia with excess blasts, s/p matched, related donor allogenic transplant (day +377 on [MASKED] with reduced intensity conditioning. Bone marrow biopsy was obtained, which demonstrated concern for relapsed MDS. [MASKED] chimerism/engraftment studies were sent the day prior to discharge. Was treated supportively and received three units of pRBCs during his hospitalization. # SIADH. Was hyponatremic to 125 in the setting of initiating Bactrim. Free water challenge test was performed with elevated urine osmolality, which confirmed SIADH. # Right knee pain. Endorsed three days of right knee pain prior to admission. Plain film demonstrated no fracture or effusion. Pain improved with diuresis. =================== TRANSITIONAL ISSUES =================== # Antibiotic course: Will be discharged with imipenem 500 mg q6h and minocycline 200 mg PO BID for a course ending tentatively [MASKED], at which point he will be re-imaged. Will require weekly CBC w/ differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS. All lab results should be sent to: ATTN: [MASKED] CLINIC - FAX: [MASKED]. Will have outpatient ID follow-up. # Immunosuppression. Cyclosporine discontinued. Prednisone decreased to 7.5 mg daily. # Atrial fibrillation. Will be discharged on metoprolol succinate 150 mg bid, and diltiazem XL 360 mg daily. Anticoagulation was halted given CHA2DS2-Vasc score of 2. # Discharge weight: 175.1 lbs # Code status: FULL # Contact: [MASKED], wife, [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Atovaquone Suspension 750 mg PO DAILY 3. Budesonide 3 mg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 5. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 6. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 7. Diltiazem Extended-Release 240 mg PO DAILY 8. FoLIC Acid 1 mg PO FIVE TIMES DAILY 9. Furosemide 20 mg PO DAILY 10. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 11. Lorazepam 0.5 mg PO QHS 12. Metoprolol Succinate XL 50 mg PO DAILY 13. Pantoprazole 40 mg PO Q12H 14. Posaconazole Delayed Release Tablet 100 mg PO TID 15. Potassium Chloride 20 mEq PO DAILY 16. PredniSONE 10 mg PO DAILY 17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 18. Ursodiol 300 mg PO BID 19. Warfarin Dose is Unknown PO Frequency is Unknown 20. Vitamin D [MASKED] UNIT PO DAILY 21. copper gluconate 2 mg oral DAILY 22. Magnesium Oxide 400 mg PO BID 23. Multivitamins 1 TAB PO DAILY 24. Bisacodyl 10 mg PO DAILY:PRN constipation 25. Docusate Sodium 100 mg PO BID 26. Oxymetazoline 1 SPRY NU Frequency is Unknown 27. Simethicone 80 mg PO QID:PRN gas and bloating Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. copper gluconate 3 mg oral DAILY 4. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 5. Docusate Sodium 100 mg PO BID 6. Hydrocortisone Acetate Suppository AILY PRN hemorrhoids 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Simethicone 80 mg PO QID:PRN gas and bloating 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 11. Ursodiol 300 mg PO BID 12. Vitamin D [MASKED] UNIT PO DAILY 13. Imipenem-Cilastatin 500 mg IV Q6H 14. Cyclosporine 0.05% Ophth Emulsion 2 gtt Other BID 15. Lorazepam 0.5 mg PO QHS 16. Atovaquone Suspension 1500 mg PO DAILY 17. Diltiazem Extended-Release 360 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. Metoprolol Succinate XL 150 mg PO BID 20. Posaconazole Delayed Release Tablet 100 mg PO TID 21. PredniSONE 7.5 mg PO DAILY 22. Minocycline 200 mg PO BID 23. Magnesium Oxide 400 mg PO BID 24. Outpatient Lab Work Diagnosis: Pulmonary Nocardiosis (ICD-10: A43.0) Please check weekly: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] 25. Budesonide 3 mg PO TID 26. FoLIC Acid 5 mg PO DAILY 27. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Discharge Diagnosis: ================= PRIMARY DIAGNOSES ================= - myelodysplastic syndrome, type 2 (refractory anemia with excess blasts) - pulmonary Nocardiosis - atrial fibrillation with rapid ventricular response =================== SECONDARY DIAGNOSES =================== - obstructive sleep apnea - history of aspergillosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. You were admitted for shortness of breath, increased swelling in your legs, and rapid heart rate. While you were here, we controlled your heart rate with metoprolol and diltiazem. You were also found to have an infection in your lung, which was biopsied and demonstrated a bacteria called "Nocardia." You have been started on an extended course of antibiotics for this infection. We gave you a medication called Lasix to remove fluid from your body and decrease the swelling in your legs. You also developed a significant diarrhea, which we think was related to one of the antibiotics that we stopped. You will be going to a rehabilitation facility to continue your recovery. Please continue to take all medications as prescribed. We wish you the very best! Warmly, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I480", "G4733", "Z7901", "Z87891", "I10", "K219" ]
[ "A430: Pulmonary nocardiosis", "D4622: Refractory anemia with excess of blasts 2", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "Z9484: Stem cells transplant status", "E8770: Fluid overload, unspecified", "I480: Paroxysmal atrial fibrillation", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R197: Diarrhea, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z803: Family history of malignant neoplasm of breast", "T370X5A: Adverse effect of sulfonamides, initial encounter", "M25561: Pain in right knee" ]
10,064,176
20,435,773
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year-old who is ___ presented to the emergency room at ___. He denied any fever he did report a prior questionable ankle infection about ___ years ago seen by orthopedic surgery and underwent left ankle arthrocentesis he was taken to the operating room on ___ underwent left ankle arthrotomy and I&D washout and then repeatedly back on ___ he was recently discharged on 1019 on IV Kefzol he has been followed by the ID department. On ___ called orthopedics on call about persistent pain in his ankle is advised to go to the clinic but he wound up going to the emergency room in ___ who removed the cast and gave him a new one there is no no knowledge of any DVT workup being done. During his hospitalization he had noninvasives that showed no DVT. On ___ he came to the ___ clinic and underwent a cast change he then complained of pain and went and saw I believe the pain service at ___ where he is followed they contacted his primary care doctor who felt he would need to have his cast off she contacted orthopedic surgery to arrange for this I had him come in today to the ___ clinic. His cast was removed. He says if he moves his ankle he has excruciating pain he has no numbness or tingling in his feet. Past Medical History: DIVERTICULOSIS, s/p diverticulitis w/ partial sigmoidectomy LUMBAR PAIN-Facet arthropathy ESOPHAGITIS HEARING LOSS Microscopic hematuria.(followed by urology) Social History: ___ Family History: N/C Physical Exam: Vitals: AFVSS General: Well-appearing, breathing comfortably MSK: LLE: Reduced effusion relative to last admission Incision closed with nylon sutures healing well Pain with active/passive ROM No erythema Fires ___ SILT throughout WWP Pertinent Results: ___ 03:54AM BLOOD WBC-8.7 RBC-3.17* Hgb-10.1* Hct-30.8* MCV-97 MCH-31.9 MCHC-32.8 RDW-13.3 RDWSD-47.6* Plt ___ ___ 05:24PM BLOOD WBC-10.1* RBC-3.15* Hgb-10.2* Hct-30.5* MCV-97 MCH-32.4* MCHC-33.4 RDW-13.5 RDWSD-47.2* Plt ___ ___ 03:54AM BLOOD CRP-12.0* (From 40 the week prior) Brief Hospital Course: The patient was admitted to the hospital with continued L ankle pain. His exam appeared improved relative to previous but was still limited by pain. Doppler studies of the extremity were negative. MRI was performed which demonstrated possible osteomyelitis of the distal fibula and tibia. CRP was decreased to 12 from 40 the week prior. There was no ankle effusion on exam or imaging concerning for recurrent septic arthritis. The case was discussed with the ___ Disease team who agree that the picture is consistent with osteomyelitis improving on appropriate antibiotics. He will be discharged with a plan to continue his course of IV Ancef 2g q8h for an additional 2 weeks (until ___ to complete a 6 week osteomyelitis course. The patient was in agreement with this plan. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO BID 5. CeFAZolin 2 g IV Q8H Continue this course until ___ (2 weeks longer than originally planned) RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every eight (8) hours Disp #*14 Intravenous Bag Refills:*0 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left distal fibula and tibia osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Vitals: AFVSS General: Well-appearing, breathing comfortably MSK: LLE: Reduced effusion relative to last admission Incision closed with nylon sutures healing well Pain with active/passive ROM No erythema Fires ___ SILT throughout ___ Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight bearing as tolerated in CAM walking boot MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin 325 daily for 4 weeks WOUND CARE: - You may shower. - Sutures removed in the hospital DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: WBAT LLE Treatments Frequency: No treatment necessary for incision; staples removed prior to discharge Followup Instructions: ___
[ "M868X7", "M00072", "B9561", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year-old who is [MASKED] presented to the emergency room at [MASKED]. He denied any fever he did report a prior questionable ankle infection about [MASKED] years ago seen by orthopedic surgery and underwent left ankle arthrocentesis he was taken to the operating room on [MASKED] underwent left ankle arthrotomy and I&D washout and then repeatedly back on [MASKED] he was recently discharged on 1019 on IV Kefzol he has been followed by the ID department. On [MASKED] called orthopedics on call about persistent pain in his ankle is advised to go to the clinic but he wound up going to the emergency room in [MASKED] who removed the cast and gave him a new one there is no no knowledge of any DVT workup being done. During his hospitalization he had noninvasives that showed no DVT. On [MASKED] he came to the [MASKED] clinic and underwent a cast change he then complained of pain and went and saw I believe the pain service at [MASKED] where he is followed they contacted his primary care doctor who felt he would need to have his cast off she contacted orthopedic surgery to arrange for this I had him come in today to the [MASKED] clinic. His cast was removed. He says if he moves his ankle he has excruciating pain he has no numbness or tingling in his feet. Past Medical History: DIVERTICULOSIS, s/p diverticulitis w/ partial sigmoidectomy LUMBAR PAIN-Facet arthropathy ESOPHAGITIS HEARING LOSS Microscopic hematuria.(followed by urology) Social History: [MASKED] Family History: N/C Physical Exam: Vitals: AFVSS General: Well-appearing, breathing comfortably MSK: LLE: Reduced effusion relative to last admission Incision closed with nylon sutures healing well Pain with active/passive ROM No erythema Fires [MASKED] SILT throughout WWP Pertinent Results: [MASKED] 03:54AM BLOOD WBC-8.7 RBC-3.17* Hgb-10.1* Hct-30.8* MCV-97 MCH-31.9 MCHC-32.8 RDW-13.3 RDWSD-47.6* Plt [MASKED] [MASKED] 05:24PM BLOOD WBC-10.1* RBC-3.15* Hgb-10.2* Hct-30.5* MCV-97 MCH-32.4* MCHC-33.4 RDW-13.5 RDWSD-47.2* Plt [MASKED] [MASKED] 03:54AM BLOOD CRP-12.0* (From 40 the week prior) Brief Hospital Course: The patient was admitted to the hospital with continued L ankle pain. His exam appeared improved relative to previous but was still limited by pain. Doppler studies of the extremity were negative. MRI was performed which demonstrated possible osteomyelitis of the distal fibula and tibia. CRP was decreased to 12 from 40 the week prior. There was no ankle effusion on exam or imaging concerning for recurrent septic arthritis. The case was discussed with the [MASKED] Disease team who agree that the picture is consistent with osteomyelitis improving on appropriate antibiotics. He will be discharged with a plan to continue his course of IV Ancef 2g q8h for an additional 2 weeks (until [MASKED] to complete a 6 week osteomyelitis course. The patient was in agreement with this plan. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO BID 5. CeFAZolin 2 g IV Q8H Continue this course until [MASKED] (2 weeks longer than originally planned) RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every eight (8) hours Disp #*14 Intravenous Bag Refills:*0 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left distal fibula and tibia osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Vitals: AFVSS General: Well-appearing, breathing comfortably MSK: LLE: Reduced effusion relative to last admission Incision closed with nylon sutures healing well Pain with active/passive ROM No erythema Fires [MASKED] SILT throughout [MASKED] Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight bearing as tolerated in CAM walking boot MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin 325 daily for 4 weeks WOUND CARE: - You may shower. - Sutures removed in the hospital DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: WBAT LLE Treatments Frequency: No treatment necessary for incision; staples removed prior to discharge Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "M868X7: Other osteomyelitis, ankle and foot", "M00072: Staphylococcal arthritis, left ankle and foot", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,064,176
22,232,545
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left native ankle septic arthritis Major Surgical or Invasive Procedure: Left ankle irrigation and debridement ___ (___) Repeat irrigation and debridement L ankle ___ (___) History of Present Illness: ___ male presents to the ED w/ left ankle pain. Atraumatic onset this morning which awoke him from pain. He reports a prior remote ankle infection ___ years ago). No history of gout. No baseline pain in this ankle. Subjective fever (temp to 100.5), no chills or other systemic signs of infection. Past Medical History: DIVERTICULOSIS, s/p diverticulitis w/ partial sigmoidectomy LUMBAR PAIN-Facet arthropathy ESOPHAGITIS HEARING LOSS Microscopic hematuria.(followed by urology) Social History: ___ Family History: N/C Physical Exam: AVSS General: Well-appearing male in mild discomfort Left lower extremity: In cast SILT over exposed toes, which are well perfused Pertinent Results: ___ 06:15AM BLOOD WBC-11.2* RBC-3.03* Hgb-9.8* Hct-29.8* MCV-98 MCH-32.3* MCHC-32.9 RDW-12.8 RDWSD-46.2 Plt ___ ___ 05:47AM BLOOD WBC-10.2* RBC-3.06* Hgb-9.6* Hct-30.0* MCV-98 MCH-31.4 MCHC-32.0 RDW-12.8 RDWSD-45.9 Plt ___ ___ 05:33AM BLOOD WBC-11.7* RBC-3.09* Hgb-10.0* Hct-30.4* MCV-98 MCH-32.4* MCHC-32.9 RDW-12.6 RDWSD-45.3 Plt ___ ___ 05:47AM BLOOD CRP-40.5* ___ 01:42PM BLOOD CRP-46.6* Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left native ankle septic arthritis and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for irrigation and debridement left ankle (___), The patient was taken to the operating room on ___ for repeat irrigation and debridement left ankle (___), both of which the patient tolerated well. For full details of the procedure please see the separately dictated operative reports. In each case, the patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was maintained on IV antibiotics per Infectious Disease and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. However, patient continually endorsed persistent pain despite high dose analgesia regimen. Eventual adequate pain relief was achieved on a PO regimen with the assistance of the acute pain service and the patient was discharged with plans to follow up with his Chronic Pain providers at ___. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight bearing in a cast in the left lower extremity, and will be discharged on Aspirin 325 daily for 4 weeks for DVT prophylaxis. The patient will follow up with Dr. ___ routine. He will follow up with the Infectious disease team as well per OPAT note. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Aspirin 325 mg PO DAILY 3. CeFAZolin 2 g IV Q8H Duration: 4 Weeks RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 gm q8 hours Disp #*84 Intravenous Bag Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 400 mg PO TID RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day Disp #*42 Capsule Refills:*0 6. Morphine SR (MS ___ 15 mg PO Q8H RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 7. Naproxen 500 mg PO Q12H RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 8. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - Moderate RX *oxycodone 10 mg ___ tablet(s) by mouth q3h PRN Disp #*84 Tablet Refills:*0 9. Senna 8.6 mg PO BID 10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 11. Tizanidine 4 mg PO TID RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 12. Omeprazole 20 mg PO DAILY GERD Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left native ankle infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing in cast MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take ASA 325 daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air at this point. If any drainage may use dry sterile dressing PRN DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: TDWB in cast LLE Treatments Frequency: Cast to LLE; we will take down at follow-up TDWB LLE Followup Instructions: ___
[ "M00072", "B9561", "F17210", "M79662", "Z23" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left native ankle septic arthritis Major Surgical or Invasive Procedure: Left ankle irrigation and debridement [MASKED] ([MASKED]) Repeat irrigation and debridement L ankle [MASKED] ([MASKED]) History of Present Illness: [MASKED] male presents to the ED w/ left ankle pain. Atraumatic onset this morning which awoke him from pain. He reports a prior remote ankle infection [MASKED] years ago). No history of gout. No baseline pain in this ankle. Subjective fever (temp to 100.5), no chills or other systemic signs of infection. Past Medical History: DIVERTICULOSIS, s/p diverticulitis w/ partial sigmoidectomy LUMBAR PAIN-Facet arthropathy ESOPHAGITIS HEARING LOSS Microscopic hematuria.(followed by urology) Social History: [MASKED] Family History: N/C Physical Exam: AVSS General: Well-appearing male in mild discomfort Left lower extremity: In cast SILT over exposed toes, which are well perfused Pertinent Results: [MASKED] 06:15AM BLOOD WBC-11.2* RBC-3.03* Hgb-9.8* Hct-29.8* MCV-98 MCH-32.3* MCHC-32.9 RDW-12.8 RDWSD-46.2 Plt [MASKED] [MASKED] 05:47AM BLOOD WBC-10.2* RBC-3.06* Hgb-9.6* Hct-30.0* MCV-98 MCH-31.4 MCHC-32.0 RDW-12.8 RDWSD-45.9 Plt [MASKED] [MASKED] 05:33AM BLOOD WBC-11.7* RBC-3.09* Hgb-10.0* Hct-30.4* MCV-98 MCH-32.4* MCHC-32.9 RDW-12.6 RDWSD-45.3 Plt [MASKED] [MASKED] 05:47AM BLOOD CRP-40.5* [MASKED] 01:42PM BLOOD CRP-46.6* Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left native ankle septic arthritis and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for irrigation and debridement left ankle ([MASKED]), The patient was taken to the operating room on [MASKED] for repeat irrigation and debridement left ankle ([MASKED]), both of which the patient tolerated well. For full details of the procedure please see the separately dictated operative reports. In each case, the patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was maintained on IV antibiotics per Infectious Disease and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. However, patient continually endorsed persistent pain despite high dose analgesia regimen. Eventual adequate pain relief was achieved on a PO regimen with the assistance of the acute pain service and the patient was discharged with plans to follow up with his Chronic Pain providers at [MASKED]. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight bearing in a cast in the left lower extremity, and will be discharged on Aspirin 325 daily for 4 weeks for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. He will follow up with the Infectious disease team as well per OPAT note. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Aspirin 325 mg PO DAILY 3. CeFAZolin 2 g IV Q8H Duration: 4 Weeks RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 gm q8 hours Disp #*84 Intravenous Bag Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 400 mg PO TID RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day Disp #*42 Capsule Refills:*0 6. Morphine SR (MS [MASKED] 15 mg PO Q8H RX *morphine [MS [MASKED] 15 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 7. Naproxen 500 mg PO Q12H RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 8. OxyCODONE (Immediate Release) [MASKED] mg PO Q3H:PRN Pain - Moderate RX *oxycodone 10 mg [MASKED] tablet(s) by mouth q3h PRN Disp #*84 Tablet Refills:*0 9. Senna 8.6 mg PO BID 10. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush 11. Tizanidine 4 mg PO TID RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 12. Omeprazole 20 mg PO DAILY GERD Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left native ankle infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing in cast MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take ASA 325 daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air at this point. If any drainage may use dry sterile dressing PRN DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: TDWB in cast LLE Treatments Frequency: Cast to LLE; we will take down at follow-up TDWB LLE Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "M00072: Staphylococcal arthritis, left ankle and foot", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M79662: Pain in left lower leg", "Z23: Encounter for immunization" ]
10,064,312
25,372,801
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 knee pain Major Surgical or Invasive Procedure: left total knee replacement on ___ History of Present Illness: ___ year old female with left knee osteoarthritis which has failed conservative management and has elected to proceed with a left total knee replacement on ___. Past Medical History: PMH: type 2 DM, hypercholesterolemia, depression, fibromyalgia, chronic fatigue, hypothyroidism, b/l knee OA, gout, vit D deficiency, adrenal adenoma. Pshx: R knee arthroscopy Social History: ___ Family History: non contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm 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: Overnight on POD#0, she was hypotensive with systolic BP in the ___. She was bolused 500cc of LR and responded appropriately. On POD#1, the patient's sodium was noted to be 130. This was observed and had improved to 135 without intervention on POD#2. Otherwise, pain was controlled with a combination of IV and oral pain medications.. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to home with services/rehab in stable condition Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 20 mg PO QHS 2. ARIPiprazole 2 mg PO DAILY 3. DULoxetine 40 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 7. Naproxen 500 mg PO Q12H:PRN Pain - Mild 8. Rosuvastatin Calcium 10 mg PO DAILY 9. Januvia (SITagliptin) 100 mg oral DAILY 10. Aspirin 81 mg PO DAILY 11. OneTouch Ultra Test (blood sugar diagnostic) 1 box miscellaneous as directed BID 12. OneTouch Ultra2 (blood-glucose meter) 1 kit miscellaneous BID 13. Vitamin D ___ UNIT PO DAILY 14. OneTouch UltraSoft Lancets (lancets) 1 box miscellaneous BID 15. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg oral DAILY 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 - Independent. Followup Instructions: ___
[ "M170", "I959", "E119", "E7800", "F329", "M797", "R5382", "E039", "E559", "G4733", "E669", "Z6830" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left knee pain Major Surgical or Invasive Procedure: left total knee replacement on [MASKED] History of Present Illness: [MASKED] year old female with left knee osteoarthritis which has failed conservative management and has elected to proceed with a left total knee replacement on [MASKED]. Past Medical History: PMH: type 2 DM, hypercholesterolemia, depression, fibromyalgia, chronic fatigue, hypothyroidism, b/l knee OA, gout, vit D deficiency, adrenal adenoma. Pshx: R knee arthroscopy Social History: [MASKED] Family History: non contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm 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: Overnight on POD#0, she was hypotensive with systolic BP in the [MASKED]. She was bolused 500cc of LR and responded appropriately. On POD#1, the patient's sodium was noted to be 130. This was observed and had improved to 135 without intervention on POD#2. Otherwise, pain was controlled with a combination of IV and oral pain medications.. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [MASKED] is discharged to home with services/rehab in stable condition Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 20 mg PO QHS 2. ARIPiprazole 2 mg PO DAILY 3. DULoxetine 40 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 7. Naproxen 500 mg PO Q12H:PRN Pain - Mild 8. Rosuvastatin Calcium 10 mg PO DAILY 9. Januvia (SITagliptin) 100 mg oral DAILY 10. Aspirin 81 mg PO DAILY 11. OneTouch Ultra Test (blood sugar diagnostic) 1 box miscellaneous as directed BID 12. OneTouch Ultra2 (blood-glucose meter) 1 kit miscellaneous BID 13. Vitamin D [MASKED] UNIT PO DAILY 14. OneTouch UltraSoft Lancets (lancets) 1 box miscellaneous BID 15. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg oral DAILY 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 - Independent. Followup Instructions: [MASKED]
[]
[ "E119", "F329", "E039", "G4733", "E669" ]
[ "M170: Bilateral primary osteoarthritis of knee", "I959: Hypotension, unspecified", "E119: Type 2 diabetes mellitus without complications", "E7800: Pure hypercholesterolemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M797: Fibromyalgia", "R5382: Chronic fatigue, unspecified", "E039: Hypothyroidism, unspecified", "E559: Vitamin D deficiency, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult" ]
10,064,390
23,328,727
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Mechanical fall resulting in subarachnoid hemorrhage Major Surgical or Invasive Procedure: ___ ACDF of C5-C6 with Dr. ___ ___ of Present Illness: Mr. ___ is a ___ year old gentleman who sustained a fall on ___ after slipping on ice while walking his dog. He was down for an unknown amount of time until his wife found him at the bottom of his driveway. He was found to be awake, although not moving his upper or lower extremities and was amnestic to the event. The patient was taken to ___ ___ where he was able to weakly raise his BLE, and had minimally weak movement to his BUE. The patient stated that he had decreased sensation to his lower body from below his nipple line, and endorsed double vision. A NCHCT was performed and was consistent with a perimesencephalic SAH with extension into the fourth ventricle. A CT C-spine was performed and was concerning for c5-c6 posterior osteophyte. The patient was intubated at the OSH for declining mental status and was transferred to ___ via MED Flight for further care and evaluation. Neurosurgery was consulted, the patient was examined and images were reviewed. A repeat NCHCT/CTA was performed to assess for vascular abnormality and interval change, and a CT of the chest abdomen and pelvis was done in the setting of trauma and was negative for injuries or fractures. Past Medical History: HTN, HLD, restless leg syndrome Social History: ___ Family History: ___ contributory Physical Exam: Exam on admission ___: Intubated. EO spont. Follows commands. Hyper-reflexive with increased tone on all extremities. + clonus and + hoffmans bilaterally. Pinpoint pupils on sedation. Shows thumb/2 fingers on R. ___ withdraws to deep noxious. BLE withdraw to noxious. Decreased rectal tone. On Discharge: Alert and oriented, follows complex commands, endoreses paresthesias to all 5 fingers on bilateral hands to front and back of fingers, incision OTA w/ steri strips Motor Exam: Delt Trap Bi Tri Grip IP Q H AT ___ ___ Right 4 5 5 4 1 4 5 4 5 5 5 Left 4 5 4 3 1 4 5 4 5 5 5 Pertinent Results: ___: CTA Head Subarachnoid hemorrhage in the basal cisterns predominant on the right, with some redistribution from prior exam. No new focus of hemorrhage or infarction. ___: MRI c-spine 1. Study is mildly degraded by motion. 2. Severe C5-C6 spinal canal stenosis with focal cervical spinal cord signal abnormality. While findings may represent myelomalacia, acute cord injury is not excluded on the basis of this examination. 3. Within limits of study, no definite acute cord infarct identified. 4. Multilevel multifactorial degenerative disease of the cervical spine, worst at C5-C6, where there is severe spinal canal and bilateral neural foramen stenosis. 5. Severe neural foramen stenosis at C4-C5 and C6-C7 as described. ___: Chest xray Previous moderate pulmonary edema has improved. Given the lung volumes are greater, there is more consolidation at the left lung base, presumably atelectasis. The severity of right basal consolidation is stable. This is either atelectasis or pneumonia. Small pleural effusions are presumed. Heart size normal. ET tube in standard placement. ___: NCHCT Subarachnoid hemorrhage in the basal cisterns, predominantly on the right and similar in appearance to prior exam. Interval redistribution of blood products to the sulci and ventricular system. No new acute findings. ___ CERVICAL SINGLE VIEW IN OR 5 intraoperative plain films were obtained without a radiologist present. These depict anterior fusion at C5-C6 with anterior plate, screws, and interbody spacer. For further information, please refer to operative report in ___ Brief Hospital Course: On ___ Pt arrived to ___ ED via medflight from ___ s/p unwitnessed fall where he was found down in his driveway by his wife while he was out walking his dog. He was down for an unknown amount of time and was initially found to be unable to move all extremities. He also had decreased sensation from his nipple line down. Due to question of posturing and possible seizure he was given 1G Keppra at OSH and intubated for change of mental status. A head CT at the OSH shows SAH CT of c-spine was concerning for posterior osteophyte at C5-C6. Patient was placed in a c-collar, transferred to ICU. MRI c-spine ordered for today. Repeat NCHCT ordered for tomorrow morning. On ___ the MRI C Spine was reviewed by Dr. ___ it is believed the findings are chronic changes, therefore no OR intervention is needed. The patient remains intubated and in hard c-collar. Patient has been febrile today, blood and urine cultures are pending. Chest xray is concerning for pneumonia and patient was started on antibiotics. An xray of the R hand was negative for fracture. Non-contrast head CT shows a stable SAH with interval redistribution of blood. On ___, the patient remained neurologically and hemodynamically stable. CXR was consistent with pneumonia, and BAL was obtained. He was treated empirically and remained intubated. He was restarted on subcutaneous heparin for DVT prophylaxis. On ___, the patient remained neurologically and hemodynamically stable. On ___, the patient remained neurologically and hemodynamically stable. Antibiotics were discontinued. Potential C5-C6 ACDF was discussed with the family. On ___, the patient remained neurologically and hemodynamically stable. He was febrile to 102.3 and cultures were repeated. On ___, the patient was extubated in the early afternoon. He remained neurologically and hemodynamically stable and it was determined he would be transferred to the floor with telemetry and was placed on continuous O2 monitoring. He failed a voiding trial and his foley catheter was replaced. He was noted to have increased secretions later in the day. On ___, the patient remained neurologically stable on examination. A Speech Swallow Evaluation was consulted for questionable aspiration and strict NPO was recommended until swelling improves. A Dobhoff was placed, confirmed with chest X-ray and tube feeds were started. He was also started on gabapentin for pain management. He continued to mobilize with nursing and ___ and was out of bed to the chair. On ___ Mr. ___ exam remained stable. His strength in lower extremities continues to improve. A Dobhoff remained in place and he is awaiting a speech and swallow re-evaluation today. He again failed Speech and swallow eval later in the day. On ___ he was offered a bed at rehab which was accepted. He was discharged to rehab with instructions for followup and all questions were answered prior to discharge. Medications on Admission: Hydrochlorothiazide Atorvastatin Multivitamin Fish oil Vitamin E Vitamin D Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. CefePIME 2 g IV Q12H 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg IV Q12H 6. Gabapentin 300 mg PO TID 7. Heparin 5000 UNIT SC BID 8. HydrALAzine 10 mg IV Q6H:PRN SBP >160 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. LeVETiracetam 500 mg IV BID 11. Morphine Sulfate 1 mg IV Q3H:PRN pain 12. Ondansetron 4 mg IV Q8H:PRN nausea / vomting 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 14. Pramipexole 0.125 mg PO QID 15. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: SAH, C5-C6 spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: **** Instructions for Traumatic Subarachnoid Hemorrhage**** 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 have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •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 **** Instructions for Cervical Spine Injury **** •Your incision is closed with dissolvable sutures underneath the skin and steri strips. You do not need suture removal. Do not remove your steri strips, let them fall off. •Please keep your incision dry for 72 hours after surgery. •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. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc… for 2 weeks. •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: ___
[ "S14125A", "J690", "J9690", "M5002", "R295", "S14126A", "W000XXA", "Y92008", "R4182", "M2578", "I10", "E785", "G2581", "D649", "M069" ]
Allergies: Iodinated Contrast Media - IV Dye Chief Complaint: Mechanical fall resulting in subarachnoid hemorrhage Major Surgical or Invasive Procedure: [MASKED] ACDF of C5-C6 with Dr. [MASKED] [MASKED] of Present Illness: Mr. [MASKED] is a [MASKED] year old gentleman who sustained a fall on [MASKED] after slipping on ice while walking his dog. He was down for an unknown amount of time until his wife found him at the bottom of his driveway. He was found to be awake, although not moving his upper or lower extremities and was amnestic to the event. The patient was taken to [MASKED] [MASKED] where he was able to weakly raise his BLE, and had minimally weak movement to his BUE. The patient stated that he had decreased sensation to his lower body from below his nipple line, and endorsed double vision. A NCHCT was performed and was consistent with a perimesencephalic SAH with extension into the fourth ventricle. A CT C-spine was performed and was concerning for c5-c6 posterior osteophyte. The patient was intubated at the OSH for declining mental status and was transferred to [MASKED] via MED Flight for further care and evaluation. Neurosurgery was consulted, the patient was examined and images were reviewed. A repeat NCHCT/CTA was performed to assess for vascular abnormality and interval change, and a CT of the chest abdomen and pelvis was done in the setting of trauma and was negative for injuries or fractures. Past Medical History: HTN, HLD, restless leg syndrome Social History: [MASKED] Family History: [MASKED] contributory Physical Exam: Exam on admission [MASKED]: Intubated. EO spont. Follows commands. Hyper-reflexive with increased tone on all extremities. + clonus and + hoffmans bilaterally. Pinpoint pupils on sedation. Shows thumb/2 fingers on R. [MASKED] withdraws to deep noxious. BLE withdraw to noxious. Decreased rectal tone. On Discharge: Alert and oriented, follows complex commands, endoreses paresthesias to all 5 fingers on bilateral hands to front and back of fingers, incision OTA w/ steri strips Motor Exam: Delt Trap Bi Tri Grip IP Q H AT [MASKED] [MASKED] Right 4 5 5 4 1 4 5 4 5 5 5 Left 4 5 4 3 1 4 5 4 5 5 5 Pertinent Results: [MASKED]: CTA Head Subarachnoid hemorrhage in the basal cisterns predominant on the right, with some redistribution from prior exam. No new focus of hemorrhage or infarction. [MASKED]: MRI c-spine 1. Study is mildly degraded by motion. 2. Severe C5-C6 spinal canal stenosis with focal cervical spinal cord signal abnormality. While findings may represent myelomalacia, acute cord injury is not excluded on the basis of this examination. 3. Within limits of study, no definite acute cord infarct identified. 4. Multilevel multifactorial degenerative disease of the cervical spine, worst at C5-C6, where there is severe spinal canal and bilateral neural foramen stenosis. 5. Severe neural foramen stenosis at C4-C5 and C6-C7 as described. [MASKED]: Chest xray Previous moderate pulmonary edema has improved. Given the lung volumes are greater, there is more consolidation at the left lung base, presumably atelectasis. The severity of right basal consolidation is stable. This is either atelectasis or pneumonia. Small pleural effusions are presumed. Heart size normal. ET tube in standard placement. [MASKED]: NCHCT Subarachnoid hemorrhage in the basal cisterns, predominantly on the right and similar in appearance to prior exam. Interval redistribution of blood products to the sulci and ventricular system. No new acute findings. [MASKED] CERVICAL SINGLE VIEW IN OR 5 intraoperative plain films were obtained without a radiologist present. These depict anterior fusion at C5-C6 with anterior plate, screws, and interbody spacer. For further information, please refer to operative report in [MASKED] Brief Hospital Course: On [MASKED] Pt arrived to [MASKED] ED via medflight from [MASKED] s/p unwitnessed fall where he was found down in his driveway by his wife while he was out walking his dog. He was down for an unknown amount of time and was initially found to be unable to move all extremities. He also had decreased sensation from his nipple line down. Due to question of posturing and possible seizure he was given 1G Keppra at OSH and intubated for change of mental status. A head CT at the OSH shows SAH CT of c-spine was concerning for posterior osteophyte at C5-C6. Patient was placed in a c-collar, transferred to ICU. MRI c-spine ordered for today. Repeat NCHCT ordered for tomorrow morning. On [MASKED] the MRI C Spine was reviewed by Dr. [MASKED] it is believed the findings are chronic changes, therefore no OR intervention is needed. The patient remains intubated and in hard c-collar. Patient has been febrile today, blood and urine cultures are pending. Chest xray is concerning for pneumonia and patient was started on antibiotics. An xray of the R hand was negative for fracture. Non-contrast head CT shows a stable SAH with interval redistribution of blood. On [MASKED], the patient remained neurologically and hemodynamically stable. CXR was consistent with pneumonia, and BAL was obtained. He was treated empirically and remained intubated. He was restarted on subcutaneous heparin for DVT prophylaxis. On [MASKED], the patient remained neurologically and hemodynamically stable. On [MASKED], the patient remained neurologically and hemodynamically stable. Antibiotics were discontinued. Potential C5-C6 ACDF was discussed with the family. On [MASKED], the patient remained neurologically and hemodynamically stable. He was febrile to 102.3 and cultures were repeated. On [MASKED], the patient was extubated in the early afternoon. He remained neurologically and hemodynamically stable and it was determined he would be transferred to the floor with telemetry and was placed on continuous O2 monitoring. He failed a voiding trial and his foley catheter was replaced. He was noted to have increased secretions later in the day. On [MASKED], the patient remained neurologically stable on examination. A Speech Swallow Evaluation was consulted for questionable aspiration and strict NPO was recommended until swelling improves. A Dobhoff was placed, confirmed with chest X-ray and tube feeds were started. He was also started on gabapentin for pain management. He continued to mobilize with nursing and [MASKED] and was out of bed to the chair. On [MASKED] Mr. [MASKED] exam remained stable. His strength in lower extremities continues to improve. A Dobhoff remained in place and he is awaiting a speech and swallow re-evaluation today. He again failed Speech and swallow eval later in the day. On [MASKED] he was offered a bed at rehab which was accepted. He was discharged to rehab with instructions for followup and all questions were answered prior to discharge. Medications on Admission: Hydrochlorothiazide Atorvastatin Multivitamin Fish oil Vitamin E Vitamin D Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. CefePIME 2 g IV Q12H 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg IV Q12H 6. Gabapentin 300 mg PO TID 7. Heparin 5000 UNIT SC BID 8. HydrALAzine 10 mg IV Q6H:PRN SBP >160 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. LeVETiracetam 500 mg IV BID 11. Morphine Sulfate 1 mg IV Q3H:PRN pain 12. Ondansetron 4 mg IV Q8H:PRN nausea / vomting 13. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain 14. Pramipexole 0.125 mg PO QID 15. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: SAH, C5-C6 spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: **** Instructions for Traumatic Subarachnoid Hemorrhage**** 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 have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •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 **** Instructions for Cervical Spine Injury **** •Your incision is closed with dissolvable sutures underneath the skin and steri strips. You do not need suture removal. Do not remove your steri strips, let them fall off. •Please keep your incision dry for 72 hours after surgery. •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. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc for 2 weeks. •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]
[]
[ "I10", "E785", "D649" ]
[ "S14125A: Central cord syndrome at C5 level of cervical spinal cord, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "M5002: Cervical disc disorder with myelopathy, mid-cervical region", "R295: Transient paralysis", "S14126A: Central cord syndrome at C6 level of cervical spinal cord, initial encounter", "W000XXA: Fall on same level due to ice and snow, initial encounter", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R4182: Altered mental status, unspecified", "M2578: Osteophyte, vertebrae", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G2581: Restless legs syndrome", "D649: Anemia, unspecified", "M069: Rheumatoid arthritis, unspecified" ]
10,064,636
23,056,758
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Opioid overdose Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of opioid use disorder, and history of multiple overdoses who presents with non-cardiogenic pulmonary edema in the setting of opiate abuse and getting Narcan. The patient overdosed on Fentanyl yesterday and found unconscious by his family. EMG gave him narcan on arrival and was transferred to the ___ where he was observed for 4 hours with improvement in his MS. ___ that ___ visit, he had some sensation of fluids in his lungs and was coughing. However, that sensation resolved by the end of the ___ stay. He was discharged home and after 15 hr was found down by family again who gave him 2 dose of IN narcan and still was unresponsive. EMS came and gave him 10 mg of Narcan. He was more arousable and Satting ___ on none rebreather and transferred to the ___ On presentation was sating 97% on NR tachycardic to 107. Initial labs notable for WBC= 21.0. Hb 15, Na= 135, K= 4.4, Cr = 1.9. He complained of increasing shoftness of breath and was placed on BiPAP with slight improvement in his symptoms. A trial of BiPAP weaning was attempted but the patient was very symptomatic and desated to low 90’s on NC. The BiPAP was reapplied and since there were no ICU beds at OSH he was transferred to the ___ for further management. On arrival to the ___ ___, he had no fevers, chills, CP, vomiting, diarrhea, urinary symptoms. Temp 98.6 HR 98 BP 146/73 RR 14 POx 100% Bipap Exam notable for coarse breath sounds bilaterally. No lower extremity edema. Soft and non-tender abdomen. A trial of BiPAP weaning was attempted but the patient was very symptomatic with agitation and sensation that he is suffocating. Labs significant for: pH 7.36 pCO2 59 pO2 83 HCO3 35 BUN 22 Creatinine 1.3 WBC 27.7 No medications were given. Imaging notable for: Bilateral pulmonary edema. He was transferred to the MICU for continued BiPAP requirement. Past Medical History: Asthma Opioid use disorder Alcohol use disorder Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: bilateral crackles on inspiration, 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 DISCHARGE PHYSICAL EXAM ======================= VITALS: ___ 0753 Temp: 98.0 PO BP: 96/61 L Lying HR: 62 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: Well-developed, well-nourished male sitting in a chair near the window. HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Sclera anicteric. No oropharyngeal lesions. CV: RRR, normal S1/S2, no murmurs, rubs, or gallops RESP: CTAB, no wheezes, rales, or rhonchi GI: Soft, nontender, nondistended. NABS. No rebound or guarding. MSK: No ___ edema SKIN: No lesions or rashes NEURO: CNII-XII grossly intact. No focal deficits. Answering all questions appropriately. PSYCH: Appropriate mood and affect. Pertinent Results: ADMISSION LABS =============== ___ 06:31AM BLOOD WBC-27.7* RBC-5.57 Hgb-15.1 Hct-45.8 MCV-82 MCH-27.1 MCHC-33.0 RDW-13.2 RDWSD-39.0 Plt ___ ___ 06:31AM BLOOD Glucose-117* UreaN-22* Creat-1.3* Na-137 K-4.9 Cl-91* HCO3-28 AnGap-18 ___ 06:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 ___ 06:31AM BLOOD CK(CPK)-2885* ___ 06:36AM BLOOD ___ pO2-83* pCO2-59* pH-7.36 calTCO2-35* Base XS-5 DISCHARGE LABS ================ ___ 06:00AM BLOOD WBC-12.4* RBC-4.76 Hgb-12.9* Hct-38.9* MCV-82 MCH-27.1 MCHC-33.2 RDW-12.9 RDWSD-38.6 Plt ___ ___ 06:00AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-92* HCO3-31 AnGap-12 ___ 06:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 IMAGING STUDIES ================ CXR ___ The appearances uncharacteristic for pulmonary edema. The differential diagnosis would include viral pneumonia and inhalation injury. Correlation with history is recommended. CXR ___ Persisting, but decreased extent of interstitial abnormalities, differential considerations are unchanged including pulmonary edema, viral pneumonia and inhalation injury. MICROBIOLOGY ============ Blood and urine cultures negative at time of discharge. Brief Hospital Course: ___ with asthma, opioid use disorder, alcohol use disorder, and recent discharge from OSH ___ after a fentanyl dose presented to ___ following a fentanyl overdose. He was found down by family and given Narcan. Hospital course complicated by hypoxemic respiratory failure requiring brief MICU admission for BiPAP. # Hypoxemic respiratory failure CXR concerning for pulmonary edema that is suspected to have been from inhalation injury vs. aspiration event vs. Narcan administration. Patient was initially admitted to MICU for BiPAP given his respiratory failure but did not require intubation. On the day after admission, he was weaned off of BiPAP and transferred to the medical floor for further management. On the medical floor, he was weaned to room air. Notably, the patient had a fever the night of transfer to 101.2 associated with a WBC of 27.7, for which CAP treatment with ceftriaxone and azithromycin were initiated. The following morning, the patient's WBC downtrended to 12.9 and he had no recurrences of his fever, so antibiotics were discontinued. He remained afebrile after antibiotic discontinuation. # Fentanyl overdose s/p Narcan There was some concern by family that this may have been a suicide attempt, however the patient adamantly refused this notion. He was assessed by psychiatry who felt that 1:1 sitter was not necessary. They suggested consider naltrexone, suboxone, or methadone for pharmacologic treatment of his opioid use disorder. This can be considered in the outpatient setting. # ___ Presented with Cr reportedly 1.7 at OSH, downtredned to 0.9 while at ___. Suspect that it was likely prerenal, though the possibility of rhabdomyolysis in the setting of a elevated CK (2885) was also considered. IVF were deferred in the setting of pulmonary edema. UA was negative for myoglobinuria. His Cr prior to discharge was 0.9. Transitional Issues ===================== [ ] Opioid use disorder treatment - as above. Patient will likely need to be plugged in with OBAT as outpatient for consideration of pharmacologic treatment of his opioid use disorder. [ ] Discharged w/ prescription for Narcan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea Discharge Medications: 1. Narcan (naloxone) 4 mg/actuation nasal X2 PRN RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasally Every ___ minutes Disp #*1 Spray Refills:*3 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================== Opioid overdose Hypoxemic respiratory failure ___ 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 ___ from ___. WHY WAS I ADMITTED? =================== - You overdosed on fentanyl and required Narcan. - You were having difficulty breathing from extra fluid in your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ============================================= - We treated your difficulty breathing with extra oxygen supplied through a mask. - Your kidney's were slightly damaged when you came in, but recovered well without any medications. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================= - We connected you with a primary care doctor as below. - Continue to work on finding a program to help with your opioid use disorder. It was a pleasure caring for you! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "T404X1A", "J9601", "N179", "J702", "Y92018", "J45909", "F1010", "Z87891", "R5081", "D72829", "F1290", "F1190", "Z23" ]
Allergies: No Allergies/ADRs on File Chief Complaint: Opioid overdose Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of opioid use disorder, and history of multiple overdoses who presents with non-cardiogenic pulmonary edema in the setting of opiate abuse and getting Narcan. The patient overdosed on Fentanyl yesterday and found unconscious by his family. EMG gave him narcan on arrival and was transferred to the [MASKED] where he was observed for 4 hours with improvement in his MS. [MASKED] that [MASKED] visit, he had some sensation of fluids in his lungs and was coughing. However, that sensation resolved by the end of the [MASKED] stay. He was discharged home and after 15 hr was found down by family again who gave him 2 dose of IN narcan and still was unresponsive. EMS came and gave him 10 mg of Narcan. He was more arousable and Satting [MASKED] on none rebreather and transferred to the [MASKED] On presentation was sating 97% on NR tachycardic to 107. Initial labs notable for WBC= 21.0. Hb 15, Na= 135, K= 4.4, Cr = 1.9. He complained of increasing shoftness of breath and was placed on BiPAP with slight improvement in his symptoms. A trial of BiPAP weaning was attempted but the patient was very symptomatic and desated to low 90’s on NC. The BiPAP was reapplied and since there were no ICU beds at OSH he was transferred to the [MASKED] for further management. On arrival to the [MASKED] [MASKED], he had no fevers, chills, CP, vomiting, diarrhea, urinary symptoms. Temp 98.6 HR 98 BP 146/73 RR 14 POx 100% Bipap Exam notable for coarse breath sounds bilaterally. No lower extremity edema. Soft and non-tender abdomen. A trial of BiPAP weaning was attempted but the patient was very symptomatic with agitation and sensation that he is suffocating. Labs significant for: pH 7.36 pCO2 59 pO2 83 HCO3 35 BUN 22 Creatinine 1.3 WBC 27.7 No medications were given. Imaging notable for: Bilateral pulmonary edema. He was transferred to the MICU for continued BiPAP requirement. Past Medical History: Asthma Opioid use disorder Alcohol use disorder Social History: [MASKED] Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: bilateral crackles on inspiration, 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 DISCHARGE PHYSICAL EXAM ======================= VITALS: [MASKED] 0753 Temp: 98.0 PO BP: 96/61 L Lying HR: 62 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: Well-developed, well-nourished male sitting in a chair near the window. HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Sclera anicteric. No oropharyngeal lesions. CV: RRR, normal S1/S2, no murmurs, rubs, or gallops RESP: CTAB, no wheezes, rales, or rhonchi GI: Soft, nontender, nondistended. NABS. No rebound or guarding. MSK: No [MASKED] edema SKIN: No lesions or rashes NEURO: CNII-XII grossly intact. No focal deficits. Answering all questions appropriately. PSYCH: Appropriate mood and affect. Pertinent Results: ADMISSION LABS =============== [MASKED] 06:31AM BLOOD WBC-27.7* RBC-5.57 Hgb-15.1 Hct-45.8 MCV-82 MCH-27.1 MCHC-33.0 RDW-13.2 RDWSD-39.0 Plt [MASKED] [MASKED] 06:31AM BLOOD Glucose-117* UreaN-22* Creat-1.3* Na-137 K-4.9 Cl-91* HCO3-28 AnGap-18 [MASKED] 06:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 [MASKED] 06:31AM BLOOD CK(CPK)-2885* [MASKED] 06:36AM BLOOD [MASKED] pO2-83* pCO2-59* pH-7.36 calTCO2-35* Base XS-5 DISCHARGE LABS ================ [MASKED] 06:00AM BLOOD WBC-12.4* RBC-4.76 Hgb-12.9* Hct-38.9* MCV-82 MCH-27.1 MCHC-33.2 RDW-12.9 RDWSD-38.6 Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-92* HCO3-31 AnGap-12 [MASKED] 06:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 IMAGING STUDIES ================ CXR [MASKED] The appearances uncharacteristic for pulmonary edema. The differential diagnosis would include viral pneumonia and inhalation injury. Correlation with history is recommended. CXR [MASKED] Persisting, but decreased extent of interstitial abnormalities, differential considerations are unchanged including pulmonary edema, viral pneumonia and inhalation injury. MICROBIOLOGY ============ Blood and urine cultures negative at time of discharge. Brief Hospital Course: [MASKED] with asthma, opioid use disorder, alcohol use disorder, and recent discharge from OSH [MASKED] after a fentanyl dose presented to [MASKED] following a fentanyl overdose. He was found down by family and given Narcan. Hospital course complicated by hypoxemic respiratory failure requiring brief MICU admission for BiPAP. # Hypoxemic respiratory failure CXR concerning for pulmonary edema that is suspected to have been from inhalation injury vs. aspiration event vs. Narcan administration. Patient was initially admitted to MICU for BiPAP given his respiratory failure but did not require intubation. On the day after admission, he was weaned off of BiPAP and transferred to the medical floor for further management. On the medical floor, he was weaned to room air. Notably, the patient had a fever the night of transfer to 101.2 associated with a WBC of 27.7, for which CAP treatment with ceftriaxone and azithromycin were initiated. The following morning, the patient's WBC downtrended to 12.9 and he had no recurrences of his fever, so antibiotics were discontinued. He remained afebrile after antibiotic discontinuation. # Fentanyl overdose s/p Narcan There was some concern by family that this may have been a suicide attempt, however the patient adamantly refused this notion. He was assessed by psychiatry who felt that 1:1 sitter was not necessary. They suggested consider naltrexone, suboxone, or methadone for pharmacologic treatment of his opioid use disorder. This can be considered in the outpatient setting. # [MASKED] Presented with Cr reportedly 1.7 at OSH, downtredned to 0.9 while at [MASKED]. Suspect that it was likely prerenal, though the possibility of rhabdomyolysis in the setting of a elevated CK (2885) was also considered. IVF were deferred in the setting of pulmonary edema. UA was negative for myoglobinuria. His Cr prior to discharge was 0.9. Transitional Issues ===================== [ ] Opioid use disorder treatment - as above. Patient will likely need to be plugged in with OBAT as outpatient for consideration of pharmacologic treatment of his opioid use disorder. [ ] Discharged w/ prescription for Narcan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea Discharge Medications: 1. Narcan (naloxone) 4 mg/actuation nasal X2 PRN RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasally Every [MASKED] minutes Disp #*1 Spray Refills:*3 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================== Opioid overdose Hypoxemic respiratory failure [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] from [MASKED]. WHY WAS I ADMITTED? =================== - You overdosed on fentanyl and required Narcan. - You were having difficulty breathing from extra fluid in your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ============================================= - We treated your difficulty breathing with extra oxygen supplied through a mask. - Your kidney's were slightly damaged when you came in, but recovered well without any medications. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================= - We connected you with a primary care doctor as below. - Continue to work on finding a program to help with your opioid use disorder. It was a pleasure caring for you! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "J9601", "N179", "J45909", "Z87891" ]
[ "T404X1A: Poisoning by, adverse effect of and underdosing of other synthetic narcotics", "J9601: Acute respiratory failure with hypoxia", "N179: Acute kidney failure, unspecified", "J702: Acute drug-induced interstitial lung disorders", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "J45909: Unspecified asthma, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "Z87891: Personal history of nicotine dependence", "R5081: Fever presenting with conditions classified elsewhere", "D72829: Elevated white blood cell count, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "F1190: Opioid use, unspecified, uncomplicated", "Z23: Encounter for immunization" ]
10,064,835
21,060,575
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Depression, suicidal ideation with plan Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with a past medical history of depression who initially presented from school after calling crisis line with complaints of worsening depressed and anxious mood, suicidal thoughts with plan to overdose on medication. Psychiatry evaluated the patient in the ED and is planning to admit to inpatient psychiatry. However, she was noted to have WBC 3.2 and ANC .75, so she was admitted to medicine for further evaluation of neutropenia prior to psychiatry admission. On my evaluation, the patient reports that she recently had a bad case of the flu. It was diagnosed at the beginning of the month and she was on 5 days of Tamiflu starting on the ___. She reported that her symptoms of lightheadedness, fevers, body aches, and shortness of breath have been slow to improve. She has been on multiple medications including Tylenol, cough syrup, and albuterol inhaler, among others she can't remember. The symptoms have sequentially gotten better, but she occasionally still has to use her albuterol inhaler when she starts coughing. She had some weight loss during this episode of the flu. She has no prior history of asthma or respiratory diseases. She reports never getting the flu before. She didn't get the flu shot this year. She also had one episode of lower abdominal pain last week, which prompted her to go to urgent care. Her workup was unremarkable and her symptom went away after a few hours. She thinks she may have been constipated. Otherwise she reports no recent illnesses. She takes no chronic home medications. She eats no red meat but otherwise endorses a balanced diet. She denies prior sexual intercourse. She denies any joint pains, rashes, skin/hair/nail changes, fevers/chills or known rheumatologic conditions. She denies cigarette smoking. Rare marijuana. When she drinks alcohol at parties, she endorses drinking up to 8 shots, which she says happens about once every couple weeks and she doesn't drink at all in the interim. She has not been sleeping well in the past several weeks along with difficulty concentrating/memory, energy, appetite. Past Medical History: Depression, anxiety None but she has had three EKG's done by ___ to assess for a heart condition as her father died suddenly from a heart condition. H/o concussion - playing basketball and fell Social History: ___ Family History: Reviewed and negative for family history of known infectious, rheumatologic or other congenital diseases. She is only aware of cardiac disease in her father who died. Physical Exam: VITALS: 98.9 PO 111/55 65 18 99% ra GENERAL: Alert and in no apparent distress, lying comfortably in bed EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout Pertinent Results: WBC 3.2 -> 3.4 ANC .75 -> .95 Neut 23.3 -> 28.2 VitB12: 693 Folate: 9 HBsAg: NEG HBs Ab: POS HBc Ab: NEG CRP: 0.6 HIV Ab: NEG BLOOD ASA: NEG Ethanol: ___ Acetmnp: NEG Tricycl: NEG BLOOD HCV Ab: NEG Urine tox negative Urine UCG neg ESR pending UA negative Urine tox negative Blood smear reviewed by hematology - some atypical lymphocytes likely from recent infection, cell lines normal, not concerning ___ 08:50AM BLOOD ___ PTT-26.0 ___ ___ 09:03PM BLOOD Glucose-87 UreaN-16 Creat-0.7 Na-140 K-3.9 Cl-100 HCO3-22 AnGap-18 ___ 08:50AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-140 K-4.3 Cl-103 HCO3-25 AnGap-12 ___ 08:50AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1 ___ 09:03PM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG Brief Hospital Course: Ms. ___ is a ___ female with depression presenting with suicidal ideation with plan to overdose on medication, admitted to medicine for evaluation of incidentally discovered neutropenia. ACUTE/ACTIVE PROBLEMS: #Neutropenia #Leukopenia Incidentally discovered. It is likely that her neutropenia is related to her recent case of influenza, and may also be exacerbated by recent binge alcohol use. Ddx also includes benign ethnic neutropenia. Unlikely medication-related (no chronic medications though recently on multiple flu medications), nutritional deficiencies (B12 and folate w/in normal range), rheumatologic (CRP low, no evidence in history or exam), malignant (blood smear reviewed by hematology and with some atypical lymphocytes likely from recent infection, cell lines normal, felt to be not concerning.) HIV neg, hepatitis B and C neg. Also reassuring that her neutrophil count uptrended this morning (ANC 750 -> 950), suggesting it is more likely transient. Given that it is most likely benign and she remains asymptomatic, she does not need further inpatient workup for this issue. However, she should have repeat CBC w/ diff testing in ___ weeks to recheck her level. #Alcohol use ETOH positive on admission. Binge pattern. No evidence of withdrawal on exam. - counseling #Depression #Anxiety - hydroxyzine 25 mg q6h prn anxiety per psychiatry rec - psychiatry admission pending bed availability #Recent influenza - albuterol prn cough/SOB Transitional issue: - repeat CBC w/ diff testing in ___ weeks to reassess ANC level Medications on Admission: Albuterol prn Discharge Medications: Albuterol prn Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Major depression Suicidal ideation with plan Anxiety Neutropenia Secondary: Recent influenza Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the medicine service for evaluation of a low white blood cell count and neutrophil count. The most likely reason for these findings are your recent flu and alcohol use, and possibly also some normal genetic variation. Other testing came back normal. Please ensure that you follow up with your primary care doctor once you leave the hospital to have your complete blood count with differential checked in ___ weeks. Followup Instructions: ___
[ "F329", "R45851", "F419", "D709", "Z8709" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Depression, suicidal ideation with plan Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with a past medical history of depression who initially presented from school after calling crisis line with complaints of worsening depressed and anxious mood, suicidal thoughts with plan to overdose on medication. Psychiatry evaluated the patient in the ED and is planning to admit to inpatient psychiatry. However, she was noted to have WBC 3.2 and ANC .75, so she was admitted to medicine for further evaluation of neutropenia prior to psychiatry admission. On my evaluation, the patient reports that she recently had a bad case of the flu. It was diagnosed at the beginning of the month and she was on 5 days of Tamiflu starting on the [MASKED]. She reported that her symptoms of lightheadedness, fevers, body aches, and shortness of breath have been slow to improve. She has been on multiple medications including Tylenol, cough syrup, and albuterol inhaler, among others she can't remember. The symptoms have sequentially gotten better, but she occasionally still has to use her albuterol inhaler when she starts coughing. She had some weight loss during this episode of the flu. She has no prior history of asthma or respiratory diseases. She reports never getting the flu before. She didn't get the flu shot this year. She also had one episode of lower abdominal pain last week, which prompted her to go to urgent care. Her workup was unremarkable and her symptom went away after a few hours. She thinks she may have been constipated. Otherwise she reports no recent illnesses. She takes no chronic home medications. She eats no red meat but otherwise endorses a balanced diet. She denies prior sexual intercourse. She denies any joint pains, rashes, skin/hair/nail changes, fevers/chills or known rheumatologic conditions. She denies cigarette smoking. Rare marijuana. When she drinks alcohol at parties, she endorses drinking up to 8 shots, which she says happens about once every couple weeks and she doesn't drink at all in the interim. She has not been sleeping well in the past several weeks along with difficulty concentrating/memory, energy, appetite. Past Medical History: Depression, anxiety None but she has had three EKG's done by [MASKED] to assess for a heart condition as her father died suddenly from a heart condition. H/o concussion - playing basketball and fell Social History: [MASKED] Family History: Reviewed and negative for family history of known infectious, rheumatologic or other congenital diseases. She is only aware of cardiac disease in her father who died. Physical Exam: VITALS: 98.9 PO 111/55 65 18 99% ra GENERAL: Alert and in no apparent distress, lying comfortably in bed EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout Pertinent Results: WBC 3.2 -> 3.4 ANC .75 -> .95 Neut 23.3 -> 28.2 VitB12: 693 Folate: 9 HBsAg: NEG HBs Ab: POS HBc Ab: NEG CRP: 0.6 HIV Ab: NEG BLOOD ASA: NEG Ethanol: [MASKED] Acetmnp: NEG Tricycl: NEG BLOOD HCV Ab: NEG Urine tox negative Urine UCG neg ESR pending UA negative Urine tox negative Blood smear reviewed by hematology - some atypical lymphocytes likely from recent infection, cell lines normal, not concerning [MASKED] 08:50AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 09:03PM BLOOD Glucose-87 UreaN-16 Creat-0.7 Na-140 K-3.9 Cl-100 HCO3-22 AnGap-18 [MASKED] 08:50AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-140 K-4.3 Cl-103 HCO3-25 AnGap-12 [MASKED] 08:50AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1 [MASKED] 09:03PM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Tricycl-NEG Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with depression presenting with suicidal ideation with plan to overdose on medication, admitted to medicine for evaluation of incidentally discovered neutropenia. ACUTE/ACTIVE PROBLEMS: #Neutropenia #Leukopenia Incidentally discovered. It is likely that her neutropenia is related to her recent case of influenza, and may also be exacerbated by recent binge alcohol use. Ddx also includes benign ethnic neutropenia. Unlikely medication-related (no chronic medications though recently on multiple flu medications), nutritional deficiencies (B12 and folate w/in normal range), rheumatologic (CRP low, no evidence in history or exam), malignant (blood smear reviewed by hematology and with some atypical lymphocytes likely from recent infection, cell lines normal, felt to be not concerning.) HIV neg, hepatitis B and C neg. Also reassuring that her neutrophil count uptrended this morning (ANC 750 -> 950), suggesting it is more likely transient. Given that it is most likely benign and she remains asymptomatic, she does not need further inpatient workup for this issue. However, she should have repeat CBC w/ diff testing in [MASKED] weeks to recheck her level. #Alcohol use ETOH positive on admission. Binge pattern. No evidence of withdrawal on exam. - counseling #Depression #Anxiety - hydroxyzine 25 mg q6h prn anxiety per psychiatry rec - psychiatry admission pending bed availability #Recent influenza - albuterol prn cough/SOB Transitional issue: - repeat CBC w/ diff testing in [MASKED] weeks to reassess ANC level Medications on Admission: Albuterol prn Discharge Medications: Albuterol prn Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Major depression Suicidal ideation with plan Anxiety Neutropenia Secondary: Recent influenza Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the medicine service for evaluation of a low white blood cell count and neutrophil count. The most likely reason for these findings are your recent flu and alcohol use, and possibly also some normal genetic variation. Other testing came back normal. Please ensure that you follow up with your primary care doctor once you leave the hospital to have your complete blood count with differential checked in [MASKED] weeks. Followup Instructions: [MASKED]
[]
[ "F329", "F419" ]
[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "F419: Anxiety disorder, unspecified", "D709: Neutropenia, unspecified", "Z8709: Personal history of other diseases of the respiratory system" ]
10,064,835
28,114,476
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'm irritated, I'm here because I did what I was supposed to do." Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. ___ ___ ED Initial Psychiatry Consult note: " ___ is a ___ y/o female with a history of anxiety, no previous psych hospitalizations who is BIBA s/p aborting suicide attempt via overdose by ___. Psychiatry is consulted for evaluation and assistance with management and disposition. Ms. ___ describes that she doesn't often demonstrate her emotions and was initially very reluctant to share what happened tonight with me. Recently she began therapy with ___, her therapist on ___. She describes that she has seen ___ 5 sessions and didn't like her first therapist. ___ moved to ___ to attend ___ on a prestigious scholarship after being a high-achiever in her high school. She describes her first semester as "very lonely". She relates that she has had issues with her mother for a long time; when she was moving into her dorm, her mother and her had an argument and her mother stopped talking to her. She reports that she did not go home for ___, and when she went home over ___ break to see her siblings, her mother would not acknowledge her presence even when she was home. Her mother also did not text her or call or send her anything on the ___ birthday, despite the ___ reaching out to mother on mother's birthday. Recently in therapy, the ___ has been uncovering a lot of emotions, and she became overwhelmed after a session with her therapist today. She became upset and was studying for a test and decided that she would drink and take all of her cold medication at once to kill herself. She began drinking heavily (she thinks that earlier in the year she may have been drinking too much, but states now she only drinks socially). ___ was unable to explain to me due to distress, but essentially she aborted the attempt after drinking "a shot" and instead called for help. Campus police came to her room and brought her to the hospital; her girlfriend accompanied her/. She lists her primary supports as her girlfriend, her therapist, her mentor, and her peer group of 9 other students from ___ that received the same scholarship to ___ that she did. She has weekly mentor meetings and was expressing that although all of this is very helpful, it is slightly awkward as she has not known all of these people for very long. ___ endorses poor sleep, lack of motivation (is only doing things because her girlfriend helps her), loss of interest, poor appetite, low energy, poor concentration, guilt. Also endorses sometimes feeling as if she is being watched, but denies any psychotic or manic symptoms. COLLATERAL: * Obtained from ___, the ___ girlfriend: ___ and the ___ began dating in ___. They both opened up to each other about some of their difficulties in childhood. The ___ related that her father died at age ___ due to a heart condition and that her mother did not let the ___ have communication with her father; the ___ found out her father had died when his parents called to inform her about the funeral. ___ states that the ___ has supports and that they ___ told her she feels ashamed that she tried to attempt suicide as ___ told me that if I ever needed help, she made me promise I would call". In the ED, the ___ remained in ___ behavioral control. The ___ was admitted briefly to the medicine service for evaluation of neutropenia, which was ultimately thought to be related to viral suppression following recent significant viral illness, as well as concurrent alcohol use. Remaining work up was negative. On interview today, ___ is quite guarded and cagey surrounding the events that brought her to the hospital. She does confirm the narrative told to Dr. ___ as above. She reports that at this point she feels "fine" and back to normal, and is now becoming irritated because she feels she should not be admitted to this unit. She denies having any suicidal thinking at this time or thoughts of self harm. She shares multiple stressors that she feel result from being on the unit including having a final to complete, having to coordinate with her family about getting home, and that she is supposed to move out of the dorms on ___. She was reassured that the team is here to work with her, and our primary concern is her safety. ___ felt that she could reach out to staff if she was feeling more distressed or thinking of hurting herself. Past Medical History: PCP: ___ - ___ has had three EKG's done by ___ to assess for heart condition as her father died suddenly from a heart condition. - Denies seizure - H/o concussion - playing basketball and fell Social History: ___ Family History: Consult note, reviewed with ___, and updated as appropriate.] - ___: Father died early at age ___ due to a heart condition - Completed or attempted suicide: denies - Substance use or dependence: denies - Mental Illness: denies Physical Exam: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. Distal pulses ___ throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. No edema of the limbs. -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: ___ strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength ___ throughout. -Sensory: No deficits to fine touch throughout -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: ___ 06:00AM BLOOD WBC-3.0* RBC-4.20 Hgb-12.5 Hct-37.4 MCV-89 MCH-29.8 MCHC-33.4 RDW-14.0 RDWSD-45.3 Plt ___ ___ 08:50AM BLOOD Neuts-28.2* Lymphs-54.0* Monos-15.4* Eos-1.2 Baso-1.2* AbsNeut-0.95* AbsLymp-1.82 AbsMono-0.52 AbsEos-0.04 AbsBaso-0.04 ___ 06:00AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-141 K-4.3 Cl-103 HCO3-25 AnGap-13 ___ 08:50AM BLOOD VitB12-693 Folate-9 ___ 06:00AM BLOOD TSH-1.2 ___ 09:03PM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the ___ refused to sign a conditional voluntary agreement and was admitted on a ___, which expired on ___. At that time the ___ was not deemed to be at risk of harm to self/others and was discharged. She was also placed on q15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: ___ initially presented from school after calling crisis line with complaints of worsening depressed and anxious mood, suicidal thoughts with plan to overdose on medication. She reported endorses poor sleep, lack of motivation, loss of interest, poor appetite, low energy, poor concentration, guilt. On admission, ___ reported being irritation with being admitted and denied SI. However, she soon settled on the unit and appropriately participated in treatment. She reported that the night she called the hotline, she had felt overwhelmed by feelings brought up in therapy earlier that day. She discussed her difficult relationship with her mother, and how these feelings were exacerbated by calling her mother on mother's day. She reported one previous incident in middle school where she took pills when upset "to sleep." Her therapist reported another possible suicide attempt in ___, although the ___ denied this. The ___ reported ongoing anxiety and intermittent panic attacks since high school. She denied a history of physical or sexual trauma, although reports a period of time in high school when she became the primary caretaker for her younger siblings due to absent guardians. Given the ___ previous suicide attempt and impulsivity, would consider bipolar disorder. Would also consider PTSD as ___ reports significant family stressors as a child. Discussed with the ___ starting medication, however ___ declined. Would recommended that medication be considered as an outpatient. During admission, the ___ developed a safety plan, and listed protective factors including her insight, ability to call mentor, ability to call hotline, plan to seek out people/society when feeling down, and daily exercise at gym. She also stated that she would abstain from alcohol use. At discharge, ___ denied SI and had plans to follow up with her therapist and start Arbour IOP. 3. SUBSTANCE USE DISORDERS: On presentation to the ED, the ___ EtOH level was 108. She reported drinking two shots of vodka. During hospitalization, the ___ had good insight into how alcohol affected her judgement. The team counseled the ___ on the risk of continuing to drink alcohol, and the ___ reported that she would abstain from any additional alcohol use. 4. MEDICAL Prior to admission to psychiatry, the ___ was admitted to medicine for incidentally found leukopenia. There were no acute issues while ___ was admitted to inpatient psychiatry. ___ should follow up with her PCP ___ ___ weeks for a repeat CBC per medicine recommendations. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The ___ was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The ___ declined to participate in groups on the unit, however was observed to be social with peers. The ___ was easy to engage and pleasant in the milieu. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT Spoke with ___ outpatient psychiatrist, ___, who discussed with the team the ___ presentation over the past few months and the ___ family stressors. ___ was discharged with an appointment with Mr. ___ two days after discharge. Social work spoke with ___ mentor at ___, who reported that she had visited ___ on the unit and ___ was at baseline. She was in agreement with discharged and reported she will continue to support the ___. #) INTERVENTIONS - Medications: ___ given vistaril PRN during admission. ___ declined starting any standing medications. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: ___ discharged with follow up with her therapist and Arbour IOP. -Guardianships: N/A RISK ASSESSMENT & PROGNOSIS On presentation, the ___ was evaluated and felt to be at an increased risk of harm to herself due to SI. Her static factors noted at that time include adolescent age, history of prior suicide attempt, identification of LGBBTQ individual. Modifiable risk factors included SI, impulsiveness, intoxication, acutely stressful events, and limited coping skills. During hospitalization, the ___ continually denied SI. She had good insight into the impact of alcohol use and stated that she would not longer drink alcohol. She developed a list of ways to cope with feeling down, including calling her mentor or going to the gym. At the time of discharge, the ___ had many protective factors making her appropriate for outpatient follow up including no SI, female gender, help seeking behavior, future oriented viewpoint with motivation to continue college, no chronic substance use, good social support from her mentor, and the presence of outpatient follow up with her therapist and PHP. Our Prognosis of this ___ is fair. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This ___ is not taking any preadmission medications Discharge Medications: None Ms. ___ politely declined starting any psychiatric medications. She reported that she will reconsider that with her outpatient providers. Discharge Disposition: Home Discharge Diagnosis: Unspecified anxiety disorder r/o panic disorder r/o PTSD r/o bipolar disorder Discharge Condition: On the discharge day (___): Ms. ___ reported feeling well. She shared that she slept well (from 11pm to 8am). Attended morning opening meeting. She shared that she spoke with her mentor at the school. Vitals: T 98.4 BP 131/68 HR 86 RR 18 O2 100% RA -Appearance: Age-appearing female, wearing casual clothes, good hygiene -Behavior: calm, cooperative, engaged -Mood: 'great'. She placed mood at level 9 on scale from ___. -Affect: euthymic, mood congruent -Speech: Fluent, no dysarthria, non-pressured, normal volume. -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Denies SI, does not report AVH, no evidence of delusions. Talking about protective factors, she said:"I have many things to live for". She shared about positive plans for future: she will resume seeing therapist; she will start PHP on ___. -Insight: Fair -Judgment: Fair Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___
[ "F419", "R45851", "F410", "F4310", "F319", "D709" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I'm irritated, I'm here because I did what I was supposed to do." Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note: " [MASKED] is a [MASKED] y/o female with a history of anxiety, no previous psych hospitalizations who is BIBA s/p aborting suicide attempt via overdose by [MASKED]. Psychiatry is consulted for evaluation and assistance with management and disposition. Ms. [MASKED] describes that she doesn't often demonstrate her emotions and was initially very reluctant to share what happened tonight with me. Recently she began therapy with [MASKED], her therapist on [MASKED]. She describes that she has seen [MASKED] 5 sessions and didn't like her first therapist. [MASKED] moved to [MASKED] to attend [MASKED] on a prestigious scholarship after being a high-achiever in her high school. She describes her first semester as "very lonely". She relates that she has had issues with her mother for a long time; when she was moving into her dorm, her mother and her had an argument and her mother stopped talking to her. She reports that she did not go home for [MASKED], and when she went home over [MASKED] break to see her siblings, her mother would not acknowledge her presence even when she was home. Her mother also did not text her or call or send her anything on the [MASKED] birthday, despite the [MASKED] reaching out to mother on mother's birthday. Recently in therapy, the [MASKED] has been uncovering a lot of emotions, and she became overwhelmed after a session with her therapist today. She became upset and was studying for a test and decided that she would drink and take all of her cold medication at once to kill herself. She began drinking heavily (she thinks that earlier in the year she may have been drinking too much, but states now she only drinks socially). [MASKED] was unable to explain to me due to distress, but essentially she aborted the attempt after drinking "a shot" and instead called for help. Campus police came to her room and brought her to the hospital; her girlfriend accompanied her/. She lists her primary supports as her girlfriend, her therapist, her mentor, and her peer group of 9 other students from [MASKED] that received the same scholarship to [MASKED] that she did. She has weekly mentor meetings and was expressing that although all of this is very helpful, it is slightly awkward as she has not known all of these people for very long. [MASKED] endorses poor sleep, lack of motivation (is only doing things because her girlfriend helps her), loss of interest, poor appetite, low energy, poor concentration, guilt. Also endorses sometimes feeling as if she is being watched, but denies any psychotic or manic symptoms. COLLATERAL: * Obtained from [MASKED], the [MASKED] girlfriend: [MASKED] and the [MASKED] began dating in [MASKED]. They both opened up to each other about some of their difficulties in childhood. The [MASKED] related that her father died at age [MASKED] due to a heart condition and that her mother did not let the [MASKED] have communication with her father; the [MASKED] found out her father had died when his parents called to inform her about the funeral. [MASKED] states that the [MASKED] has supports and that they [MASKED] told her she feels ashamed that she tried to attempt suicide as [MASKED] told me that if I ever needed help, she made me promise I would call". In the ED, the [MASKED] remained in [MASKED] behavioral control. The [MASKED] was admitted briefly to the medicine service for evaluation of neutropenia, which was ultimately thought to be related to viral suppression following recent significant viral illness, as well as concurrent alcohol use. Remaining work up was negative. On interview today, [MASKED] is quite guarded and cagey surrounding the events that brought her to the hospital. She does confirm the narrative told to Dr. [MASKED] as above. She reports that at this point she feels "fine" and back to normal, and is now becoming irritated because she feels she should not be admitted to this unit. She denies having any suicidal thinking at this time or thoughts of self harm. She shares multiple stressors that she feel result from being on the unit including having a final to complete, having to coordinate with her family about getting home, and that she is supposed to move out of the dorms on [MASKED]. She was reassured that the team is here to work with her, and our primary concern is her safety. [MASKED] felt that she could reach out to staff if she was feeling more distressed or thinking of hurting herself. Past Medical History: PCP: [MASKED] - [MASKED] has had three EKG's done by [MASKED] to assess for heart condition as her father died suddenly from a heart condition. - Denies seizure - H/o concussion - playing basketball and fell Social History: [MASKED] Family History: Consult note, reviewed with [MASKED], and updated as appropriate.] - [MASKED]: Father died early at age [MASKED] due to a heart condition - Completed or attempted suicide: denies - Substance use or dependence: denies - Mental Illness: denies Physical Exam: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. Distal pulses [MASKED] throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. No edema of the limbs. -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and [MASKED] strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: [MASKED] strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength [MASKED] throughout. -Sensory: No deficits to fine touch throughout -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: [MASKED] 06:00AM BLOOD WBC-3.0* RBC-4.20 Hgb-12.5 Hct-37.4 MCV-89 MCH-29.8 MCHC-33.4 RDW-14.0 RDWSD-45.3 Plt [MASKED] [MASKED] 08:50AM BLOOD Neuts-28.2* Lymphs-54.0* Monos-15.4* Eos-1.2 Baso-1.2* AbsNeut-0.95* AbsLymp-1.82 AbsMono-0.52 AbsEos-0.04 AbsBaso-0.04 [MASKED] 06:00AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-141 K-4.3 Cl-103 HCO3-25 AnGap-13 [MASKED] 08:50AM BLOOD VitB12-693 Folate-9 [MASKED] 06:00AM BLOOD TSH-1.2 [MASKED] 09:03PM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Tricycl-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the [MASKED] refused to sign a conditional voluntary agreement and was admitted on a [MASKED], which expired on [MASKED]. At that time the [MASKED] was not deemed to be at risk of harm to self/others and was discharged. She was also placed on q15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: [MASKED] initially presented from school after calling crisis line with complaints of worsening depressed and anxious mood, suicidal thoughts with plan to overdose on medication. She reported endorses poor sleep, lack of motivation, loss of interest, poor appetite, low energy, poor concentration, guilt. On admission, [MASKED] reported being irritation with being admitted and denied SI. However, she soon settled on the unit and appropriately participated in treatment. She reported that the night she called the hotline, she had felt overwhelmed by feelings brought up in therapy earlier that day. She discussed her difficult relationship with her mother, and how these feelings were exacerbated by calling her mother on mother's day. She reported one previous incident in middle school where she took pills when upset "to sleep." Her therapist reported another possible suicide attempt in [MASKED], although the [MASKED] denied this. The [MASKED] reported ongoing anxiety and intermittent panic attacks since high school. She denied a history of physical or sexual trauma, although reports a period of time in high school when she became the primary caretaker for her younger siblings due to absent guardians. Given the [MASKED] previous suicide attempt and impulsivity, would consider bipolar disorder. Would also consider PTSD as [MASKED] reports significant family stressors as a child. Discussed with the [MASKED] starting medication, however [MASKED] declined. Would recommended that medication be considered as an outpatient. During admission, the [MASKED] developed a safety plan, and listed protective factors including her insight, ability to call mentor, ability to call hotline, plan to seek out people/society when feeling down, and daily exercise at gym. She also stated that she would abstain from alcohol use. At discharge, [MASKED] denied SI and had plans to follow up with her therapist and start Arbour IOP. 3. SUBSTANCE USE DISORDERS: On presentation to the ED, the [MASKED] EtOH level was 108. She reported drinking two shots of vodka. During hospitalization, the [MASKED] had good insight into how alcohol affected her judgement. The team counseled the [MASKED] on the risk of continuing to drink alcohol, and the [MASKED] reported that she would abstain from any additional alcohol use. 4. MEDICAL Prior to admission to psychiatry, the [MASKED] was admitted to medicine for incidentally found leukopenia. There were no acute issues while [MASKED] was admitted to inpatient psychiatry. [MASKED] should follow up with her PCP [MASKED] [MASKED] weeks for a repeat CBC per medicine recommendations. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The [MASKED] was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The [MASKED] declined to participate in groups on the unit, however was observed to be social with peers. The [MASKED] was easy to engage and pleasant in the milieu. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT Spoke with [MASKED] outpatient psychiatrist, [MASKED], who discussed with the team the [MASKED] presentation over the past few months and the [MASKED] family stressors. [MASKED] was discharged with an appointment with Mr. [MASKED] two days after discharge. Social work spoke with [MASKED] mentor at [MASKED], who reported that she had visited [MASKED] on the unit and [MASKED] was at baseline. She was in agreement with discharged and reported she will continue to support the [MASKED]. #) INTERVENTIONS - Medications: [MASKED] given vistaril PRN during admission. [MASKED] declined starting any standing medications. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: [MASKED] discharged with follow up with her therapist and Arbour IOP. -Guardianships: N/A RISK ASSESSMENT & PROGNOSIS On presentation, the [MASKED] was evaluated and felt to be at an increased risk of harm to herself due to SI. Her static factors noted at that time include adolescent age, history of prior suicide attempt, identification of LGBBTQ individual. Modifiable risk factors included SI, impulsiveness, intoxication, acutely stressful events, and limited coping skills. During hospitalization, the [MASKED] continually denied SI. She had good insight into the impact of alcohol use and stated that she would not longer drink alcohol. She developed a list of ways to cope with feeling down, including calling her mentor or going to the gym. At the time of discharge, the [MASKED] had many protective factors making her appropriate for outpatient follow up including no SI, female gender, help seeking behavior, future oriented viewpoint with motivation to continue college, no chronic substance use, good social support from her mentor, and the presence of outpatient follow up with her therapist and PHP. Our Prognosis of this [MASKED] is fair. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This [MASKED] is not taking any preadmission medications Discharge Medications: None Ms. [MASKED] politely declined starting any psychiatric medications. She reported that she will reconsider that with her outpatient providers. Discharge Disposition: Home Discharge Diagnosis: Unspecified anxiety disorder r/o panic disorder r/o PTSD r/o bipolar disorder Discharge Condition: On the discharge day ([MASKED]): Ms. [MASKED] reported feeling well. She shared that she slept well (from 11pm to 8am). Attended morning opening meeting. She shared that she spoke with her mentor at the school. Vitals: T 98.4 BP 131/68 HR 86 RR 18 O2 100% RA -Appearance: Age-appearing female, wearing casual clothes, good hygiene -Behavior: calm, cooperative, engaged -Mood: 'great'. She placed mood at level 9 on scale from [MASKED]. -Affect: euthymic, mood congruent -Speech: Fluent, no dysarthria, non-pressured, normal volume. -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Denies SI, does not report AVH, no evidence of delusions. Talking about protective factors, she said:"I have many things to live for". She shared about positive plans for future: she will resume seeing therapist; she will start PHP on [MASKED]. -Insight: Fair -Judgment: Fair Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]
[]
[ "F419" ]
[ "F419: Anxiety disorder, unspecified", "R45851: Suicidal ideations", "F410: Panic disorder [episodic paroxysmal anxiety]", "F4310: Post-traumatic stress disorder, unspecified", "F319: Bipolar disorder, unspecified", "D709: Neutropenia, unspecified" ]
10,064,854
20,184,139
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: Intubation ___ Nasogastric tube placement History of Present Illness: ___ male with HBV, longstanding bronchiectasis and recurrent PNA presenting with 1 week of worsening dyspnea, shortness of breath and cough. He had a CT chest with contrast today per his PCP which demonstrated likely malignancy vs. infection/superinfection vs ?TB. Triggered on arrival to ED for hypoxia. He reports no chest pain, no hemoptysis, no recent travel. Per daughter, has been referred to ___ multiple times in the past several years for ?TB (unclear if he was symptomatic at that time), and reports that he always gets cleared and dc'd home. CT: Severe progression multifocal bronchiectasis, bronchiolitis, and pneumonia, suggesting active mycobacterial infection including tuberculosis, or possible superinfection. In ED initial VS: 97.7, 120, 140/80, 20 85% RA ED physical exam: Constitutional::tachypneic Head/Eyes::Normocephalic, atraumatic, Extraocular muscles intact ENT/Neck::Oropharynx within normal limits Chest/Resp::coarse breath sounds Cardiovascular::tachycardic GI / Abdominal::Soft, Nontender, Nondistended GU/Flank::No costovertebral angle tenderness Musc/Extr/Back::No cyanosis, clubbing or edema, + pulses Skin::No rash, Warm and dry Neuro::Speech fluent, GCS 15 Psych::Normal mood, Normal mentation ___ petechiae ED labs notable for: Na:127 K:4.3 Cl:92 Glu:168 Lactate:6.0 Hgb:18.5 CalcHCT:56 freeCa:1.19 COHb: 1 MetHb: 0 O2Sat: 70 pH 7.34 pCO2 45 pO2 40 HCO3 25 BaseXS -1 ___: 12.9 PTT: 27.5 INR: 1.2 Fibrinogen: 106 Patient was given: ___ 13:07 IV Levofloxacin 750 mg ___ ___ 14:02 IVF NS ___ Started ___ 14:55 IVF NS 1 mL ___ Stopped (___) ___ 14:55 IVF NS ( 1000 mL ordered) ___ Started ___ 15:25 IV CeftriaXONE 1 gm ___ Stopped (___) ___ 15:26 IV Vancomycin (1000 mg ordered) ___ Started Stop Imaging notable for: CT chest: -Severe progression multifocal bronchiectasis, bronchiolitis, and pneumonia, suggesting active mycobacterial infection including tuberculosis, or possible superinfection. -Possible multifocal adenocarcinoma of the lung. -New central adenopathy due to infection and/or malignancy. -Possible of thoracic outlet syndrome reflected in severe occlusion right subclavian vein. VS prior to transfer: 98.3, 112, 141/81, 28, 96% Non-Rebreather On arrival to the MICU, pt reports continued dyspnea but denies fever/chills, CP, pleuritic pain, abdominal pain, n/v, diarrhea, or dysuria. He notes some weight loss but does not know how much. He denies additional complaints or localizing symptoms. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PULMONARY NODULE ABNORMAL CHEST CT SCAN Social History: ___ Family History: Noncontributory for lung disease. Physical Exam: Vitals: on 100% NRB. Tachyardic to ~100. GENERAL: fatigued appearing. Face is flushed. tachypneic. HEENT: AT/NC, anicteric sclera, patent nares, MMM, NECK: nontender and supple LYMPH: no cervical, supraclavicular, or axillary LAD CARDIAC: tachycardic, regular rhythmsb, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength ___ throughout, sensation grossly normal, gait intact SKIN: warm and well perfused, no excoriations or lesions, no rashes exam on discharge: Physical exam: VS: T 97.4 BP 144/80 HR 102 RR 22 O2 sat 93%2L GENERAL: Patient is sitting up in bed, responsive to voice, no apparent distress HEENT: PERRL, no scleral icterus, dry mucous membranes LUNGS: mild crackles, wheezing, and rhonchi bilaterally HEART: Normal S1S2, tachycardic, no murmurs rubs or gallops ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: Warm, well-perfused, no lower extremity edema NEURO: A&Ox3, ___ strength in upper extremities bilaterally CNII-XII intact, ___ motor strength in bilateral upper extremities. ACCESS: PICC line LUE Pertinent Results: ADMISSION: =========== ___ 10:10PM ___ PO2-70* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 ___ 09:26PM URINE HOURS-RANDOM ___ 09:26PM URINE HOURS-RANDOM ___ 09:26PM URINE HOURS-RANDOM ___ 09:26PM URINE UHOLD-HOLD ___ 09:26PM URINE GR HOLD-HOLD ___ 09:00PM ___ PO2-67* PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 ___ 09:00PM LACTATE-3.6* ___ 08:45PM GLUCOSE-130* UREA N-20 CREAT-0.6 SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 ___ 08:45PM ALT(SGPT)-48* AST(SGOT)-39 LD(LDH)-290* ALK PHOS-153* TOT BILI-1.0 ___ 08:45PM proBNP-329 ___ 08:45PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.9 URIC ACID-3.5 IRON-137 ___ 08:45PM calTIBC-256* FERRITIN-395 TRF-197* ___ 08:45PM WBC-49.6* RBC-5.42 HGB-17.5 HCT-49.5 MCV-91 MCH-32.3* MCHC-35.4 RDW-12.9 RDWSD-42.5 ___ 08:45PM NEUTS-75* BANDS-17* LYMPHS-1* MONOS-5 EOS-1 BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-45.63* AbsLymp-0.99* AbsMono-2.48* AbsEos-0.50 AbsBaso-0.00* ___ 08:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ___ 08:45PM PLT SMR-LOW PLT COUNT-129* ___ 08:45PM ___ PTT-24.9* ___ ___ 08:45PM FIBRINOGE-86* ___ 07:54PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 03:00PM HOS-AVAILABLE ___ 01:03PM TYPE-ART PO2-40* PCO2-45 PH-7.34* TOTAL CO2-25 BASE XS--1 ___ 01:03PM GLUCOSE-168* LACTATE-6.0* NA+-127* K+-4.3 CL--92* ___ 01:03PM HGB-18.5* calcHCT-56 O2 SAT-70 CARBOXYHB-1 MET HGB-0 ___ 01:03PM freeCa-1.19 ___ 12:56PM UREA N-24* CREAT-0.8 ___ 12:56PM estGFR-Using this ___ 12:56PM LIPASE-20 ___ 12:56PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:56PM WBC-61.3*# RBC-5.53 HGB-17.7*# HCT-51.1* MCV-92 MCH-32.0 MCHC-34.6 RDW-13.1 RDWSD-43.4 ___ 12:56PM NEUTS-66 BANDS-25* LYMPHS-1* MONOS-2* EOS-0 BASOS-1 ___ METAS-2* MYELOS-3* AbsNeut-55.78* AbsLymp-0.61* AbsMono-1.23* AbsEos-0.00* AbsBaso-0.61* ___ 12:56PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ___ 12:56PM PLT SMR-NORMAL PLT COUNT-155 ___ 12:56PM ___ PTT-27.5 ___ ___ 12:56PM ___ ___ 05:24AM BLOOD WBC-7.6 RBC-2.38* Hgb-7.6* Hct-23.1* MCV-97 MCH-31.9 MCHC-32.9 RDW-14.0 RDWSD-44.0 Plt ___ ___ 02:15PM BLOOD Neuts-68.1 Lymphs-16.6* Monos-12.5 Eos-2.0 Baso-0.4 Im ___ AbsNeut-3.70 AbsLymp-0.90* AbsMono-0.68 AbsEos-0.11 AbsBaso-0.02 ___ 12:52AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 06:39AM BLOOD H/O Smr-AVAILABLE ___ 08:38AM BLOOD ___ ___ 05:24AM BLOOD Glucose-121* UreaN-13 Creat-0.5 Na-140 K-4.1 Cl-99 HCO3-31 AnGap-14 ___ 02:15PM BLOOD Ret Aut-0.5 Abs Ret-0.01* ___ 05:24AM BLOOD estGFR-Using this ___ 03:57AM BLOOD CK(CPK)-62 ___ 05:49PM BLOOD CK-MB-4 cTropnT-0.01 ___ 05:24AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 ___ 02:15PM BLOOD VitB12-982* Hapto-66 ___ 02:12AM BLOOD Triglyc-147 ___ 06:39AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 02:12AM BLOOD IgG-571* IgA-179 IgM-56 ___ 12:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:31PM BLOOD HoldBLu-HOLD ___ 10:36AM BLOOD ___ pO2-98 pCO2-54* pH-7.32* calTCO2-29 Base XS-0 Comment-GREEN TOP ___ 10:36AM BLOOD Lactate-1.6 ___ 09:23AM BLOOD O2 Sat-83 ___ 09:40PM BLOOD freeCa-1.15 ___ 08:45PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test ___ 05:24AM BLOOD WBC-7.6 RBC-2.38* Hgb-7.6* Hct-23.1* MCV-97 MCH-31.9 MCHC-32.9 RDW-14.0 RDWSD-44.0 Plt ___ ___ Imaging VIDEO OROPHARYNGEAL SWA Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration but there was penetration with thin and nectar thick liquids. Moderate to large amount of residue is noted in the piriform sinuses. ___HEST W/O CONTRAST 1. Interval improvement in previously seen diffuse bilateral multifocal consolidations, centrilobular nodules, and mediastinal lymphadenopathy since the prior exam in ___, compatible with improving infection. 2. Multifocal bronchiectasis is more prominent.. 3. Small layering left pleural effusion. ___ Imaging CHEST (PORTABLE AP) Comparison to ___. The widespread bilateral parenchymal opacities have minimally decreased in extent and severity but are still clearly visible, predominating in the right upper lobe, left upper lobe and left lower lobe. The size of the cardiac silhouette is unchanged. Stable monitoring and support devices. ___ Cardiovascular ECG Sinus tachycardia with frequent premature atrial complexes. Non-diagnostic Q waves inferiorly. Non-specific ST segment changes. Compared to the previous tracing of ___ the ventricular rate is slightly faster and ventricular ectopy is no longer appreciated. Atrial ectopy is new. A short burst of a narrow complex tachycardia is no longer evident. ___ Imaging CT HEAD W/O CONTRAST There is no evidence of infarction, hemorrhage, edema, or mass. There are mild chronic small vessel ischemic changes. There is generalized brain parenchymal atrophy. There is no evidence of fracture. There is fluid in the paranasal sinuses, mastoids, right middle ear, likely related to intubation. The visualized portion of the orbits are unremarkable. ___ SPUTUM GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. MTB Direct Amplification (Final ___: CANCELLED. Specimen received less than 7 days from previous testing. PATIENT CREDITED. Reported to and read back by ___ @ 09:00, ___. LABS ON THE DAY OF DISCHARGE: ============================= ___ 06:24AM BLOOD WBC-5.9 RBC-2.69* Hgb-9.0* Hct-27.5* MCV-102* MCH-33.5* MCHC-32.7 RDW-16.6* RDWSD-61.0* Plt ___ ___ 12:52AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Brief Hospital Course: Mr. ___ is an ___ male with longstanding bronchiectasis and recurrent PNA presenting with 1 week of acutely worsening dyspnea, shortness of breath and cough and significant worsening of bronchiectasis with diffuse patchy infiltrates on CT chest, along with a hilar mass and LAD c/f malignancy vs. infection/superinfection, admitted to the MICU for management of septic shock likely secondary to Nocardia pneumonia. #Hypoxemic respiratory failure: #Nocardia PNA #AFB on sputum: Pt arrived to ED dyspneic but on RA, where he triggered for hypoxemia, requiring a NRB. His CT chest showed significant scattered nodular opacities, diffuse GGOs, interval worsening of bronchiectasis, and new hilar LAD and mass concerning for infection vs malignancy. He was admitted to the MICU and placed on high-flow O2, requiring intubation on ___ when he started fatiguing. He was briefly treated empirically with vancomycin and cefepime, then transitioned to Bactrim (___) and imipenem-cilastatin when an infectious workup, including bronchoscopy with BAL, revealed GPRs c/f Nocardia infection. Cultures from induced sputum sample from ___ confirmed Nocardia and also grew mycobacterium avium. Of note, he was s/p several workups for TB given concerning findings on imaging, all of which were negative for TB but positive for non-tuberculous mycobacterial infection (___) with unclear treatment history. Bactrim was replaced with linezolid (___-) given concern for his elevated creatinine. ID followed closely, recommencing a a ___ week course of dual therapy followed by a ___ month course of monotherapy, yet to be determined at discharge from the MICU. Significant volume overload and pulmonary edema resulting from aggressive fluid resuscitation for his septic shock of respiratory origin also contributed to his hypoxia and he required diuresis on a lasix gtt. His respiratory status slowly improved and he was extuabed on ___, then weaned from high-flow to nasal cannula prior to discharge from the medicine floor for continuation of treatment with antibiotics and management of his secretions. Respiratory status remained stable on medical floor, though had intermittent aspiration episodes causing desaturation. On the floor patient stable O2 saturations ranging between ___ on 2 L nasal cannula. He has had evaluation by speech and swallow which showed evidence of aspiration with thin and nectar thick liquids there was also moderate to large amount of residual noted in the piriform sinuses. Due to the risk of aspiration, the patient is advised to remain n.p.o. on tube feeds pending further evaluation in 2 weeks for resolution of his muscle weakness and aspiration. #Septic shock: He developed hypotension with MAPs dropping into the ___, elevated lactate, oliguria, and altered mental status, all in the setting of respiratory infection, requiring pressor support with phenylephrine, then norepinephrine and vasopressin. He was also aggressively fluid resuscitated and was net positive 20L prior to initiation of diuresis for which he required pressor support. A cardiogenic component was considered, particularly given his volume status but an TTE revealed an preserved EF and no regional or global wall motion abnormalities. He was eventually weaned off pressor with stabilization of his BP. On transfer to the floor the patient's blood pressure ranged between 110–150/50s-70s. ___: His creatinine climbed to 3.7 from baseline of 0.7 with patient becoming oliguric consistent with ATN resulting from hypoperfusion in the setting of shock, with renal injury related to contrast also likely contributing. His urine output increased several days later and he continued to autodiurese with his Cr returning to baseline at discharge from the ICU. On the floor the patient's creatinine continued to trend down to 0.4 on the day of discharge. #Thrombocytopenia: His platelet count was depressed but variable. Nadir was ___, thought secondary to bone marrow suppression from linezolid. Platelets uptrended and were stable on discharge. On the floor patient's platelets continue to improve and were 109 on discharge #Leukocytosis: The patient had a leukocytosis to 61 on admission. Heme/onc was consulted and a peripheral smear was reassuring for no underlying hematologic process. The significant white count was most consistent with a leukamoid reaction in the setting of infection and his WBC count was downtrending to normal by his discharge from the ICU. # Hypernatremia: As high as 150, secondary to poor PO intake, improved after D5W and restarting tube feeds. # weakness: likely from critical illness myopathy which is a reversible condition. His aspiration event are likely from transient muscle weakness which should improve with time. His feeding and oral medication was given through an dobhoff tube. His most recent Speech and swallow eval showed interval improvement. a re-eval in the future is required before removing the dobhoff. the dobhoff was replaced 1 day prior to discharge. #Concern for underlying lung malignancy: The hilar lymphadenopathy and question of mass was concerning for an underlying malignancy. His BAL, however, was neg for malignant cells. No additional tissue was obtained given the more pressing infection and heme/onc recommended outpatient follow-up, including re-imaging, once the acute infectious process had been addressed. Follow-up CT chest revealed decreasing adenopathy, likely consistent with infectious etiology. However malignancy cannot be completely excluded. Therefore outpatient follow-up is recommended with or without biopsy of the lesion when the general condition of this patient improves. #Hypogammaglobulinemia: His IgG was mildly depressed, likely related to consumption. A repeat level is warranted post-infection. #BPH: Both his home finasteride and tamsulosin were held in the setting of brisk urine output in the recovery phase of likely ATN, and then in the setting of an NGT. =========================== Transitional issues: –The patient has anemia and thrombocytopenia a CBC in 1 week is recommended –The patient has significant global weakness, which is likely from critical illness myopathy. He would require further evaluation as an outpatient. Neurology evaluation may be as an outpatient. –The patient has significant muscle weakness resulting in aspiration with positive video swallow test. This weakness is likely temporary from critical illness myopathy. However, neurological causes cannot be excluded. Further evaluation with speech and swallow should continue. Also further evaluation by physical therapy is required. The patient might need speech therapy to improve swallowing ability safely. –Nocardia pneumonia with underlying bronchiectasis was identified on admission. Continue imipenem and minocycline until ___. At the time of discharge Nocardia sensitivities were pending. –The patient will require IV antibiotic titration or change based on the cardia sensitivities. –The patient has a lung nodule discovered on CT on ___ concerning for lung malignancy. However, seems to be interval improvement on CT on ___. Although infection is a most likely diagnosis, malignancy cannot be excluded. A biopsy might be needed. -The patient was started on bisacodyl, imipenem cilastatin, polyethylene glycol, senna on discharge. –we stopped the patient's levofloxacin, loratadine, lorazepam, naproxen, finasteride. CODE STATUS: Full code. Contact: Wife, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Naproxen 500 mg PO ___ DAILY PRN Pain - Mild 2. LORazepam 0.5 mg PO QHS:PRN insomnia 3. Docusate Sodium 100 mg PO BID 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q6H 6. Artificial Tears ___ DROP BOTH EYES PRN dry eye 7. Loratadine 10 mg PO DAILY 8. TraZODone 50 mg PO QHS:PRN insomnia 9. Finasteride 5 mg PO DAILY 10. Tamsulosin 0.4 mg PO DAILY 11. Levofloxacin 500 mg PO Q24H Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. GuaiFENesin ___ mL PO Q6H:PRN cough 3. imipenem-cilastatin 500 mg IV Q6H 4. Minocycline 100 mg IV BID 5. Polyethylene Glycol 17 g PO DAILY:PRN contipation 6. Senna 17.2 mg PO BID:PRN constipation 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Albuterol Inhaler 2 PUFF IH Q6H 9. Artificial Tears ___ DROP BOTH EYES PRN dry eye 10. Docusate Sodium 100 mg PO BID 11. Finasteride 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Nocardia pneumonia Secondary Diagnosis: Aspiration Oropharyngeal dysphagia Anemia Discharge Condition: Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. ___, It was a pleasure treating you at ___! Why was I admitted to the hospital? -You were admitted because you were having trouble breathing, and we found that you had an infection. What happened while I was in the hospital? -We treated your infection in your lungs with antibiotics. -For some time you needed a breathing tube to help you breathe, which was removed. -You had difficulty swallowing and eating food, so we placed a feeding tube to help you get nutrition. What should I do when I am discharged? -Please continue your follow-up with your Infectious Disease doctors. -___ continue working with physical therapy to get your strength back. We wish you the best! Your ___ care providers ___: ___
[ "A419", "G9341", "N170", "J9601", "D65", "R6521", "J690", "E43", "R1312", "G7281", "E870", "A430", "I471", "D801", "C3401", "D6959", "T368X5A", "Y92230", "T370X5A", "D638", "E861", "N400", "J479", "E8809", "E875", "E8770" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation [MASKED] Nasogastric tube placement History of Present Illness: [MASKED] male with HBV, longstanding bronchiectasis and recurrent PNA presenting with 1 week of worsening dyspnea, shortness of breath and cough. He had a CT chest with contrast today per his PCP which demonstrated likely malignancy vs. infection/superinfection vs ?TB. Triggered on arrival to ED for hypoxia. He reports no chest pain, no hemoptysis, no recent travel. Per daughter, has been referred to [MASKED] multiple times in the past several years for ?TB (unclear if he was symptomatic at that time), and reports that he always gets cleared and dc'd home. CT: Severe progression multifocal bronchiectasis, bronchiolitis, and pneumonia, suggesting active mycobacterial infection including tuberculosis, or possible superinfection. In ED initial VS: 97.7, 120, 140/80, 20 85% RA ED physical exam: Constitutional::tachypneic Head/Eyes::Normocephalic, atraumatic, Extraocular muscles intact ENT/Neck::Oropharynx within normal limits Chest/Resp::coarse breath sounds Cardiovascular::tachycardic GI / Abdominal::Soft, Nontender, Nondistended GU/Flank::No costovertebral angle tenderness Musc/Extr/Back::No cyanosis, clubbing or edema, + pulses Skin::No rash, Warm and dry Neuro::Speech fluent, GCS 15 Psych::Normal mood, Normal mentation [MASKED] petechiae ED labs notable for: Na:127 K:4.3 Cl:92 Glu:168 Lactate:6.0 Hgb:18.5 CalcHCT:56 freeCa:1.19 COHb: 1 MetHb: 0 O2Sat: 70 pH 7.34 pCO2 45 pO2 40 HCO3 25 BaseXS -1 [MASKED]: 12.9 PTT: 27.5 INR: 1.2 Fibrinogen: 106 Patient was given: [MASKED] 13:07 IV Levofloxacin 750 mg [MASKED] [MASKED] 14:02 IVF NS [MASKED] Started [MASKED] 14:55 IVF NS 1 mL [MASKED] Stopped ([MASKED]) [MASKED] 14:55 IVF NS ( 1000 mL ordered) [MASKED] Started [MASKED] 15:25 IV CeftriaXONE 1 gm [MASKED] Stopped ([MASKED]) [MASKED] 15:26 IV Vancomycin (1000 mg ordered) [MASKED] Started Stop Imaging notable for: CT chest: -Severe progression multifocal bronchiectasis, bronchiolitis, and pneumonia, suggesting active mycobacterial infection including tuberculosis, or possible superinfection. -Possible multifocal adenocarcinoma of the lung. -New central adenopathy due to infection and/or malignancy. -Possible of thoracic outlet syndrome reflected in severe occlusion right subclavian vein. VS prior to transfer: 98.3, 112, 141/81, 28, 96% Non-Rebreather On arrival to the MICU, pt reports continued dyspnea but denies fever/chills, CP, pleuritic pain, abdominal pain, n/v, diarrhea, or dysuria. He notes some weight loss but does not know how much. He denies additional complaints or localizing symptoms. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PULMONARY NODULE ABNORMAL CHEST CT SCAN Social History: [MASKED] Family History: Noncontributory for lung disease. Physical Exam: Vitals: on 100% NRB. Tachyardic to ~100. GENERAL: fatigued appearing. Face is flushed. tachypneic. HEENT: AT/NC, anicteric sclera, patent nares, MMM, NECK: nontender and supple LYMPH: no cervical, supraclavicular, or axillary LAD CARDIAC: tachycardic, regular rhythmsb, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength [MASKED] throughout, sensation grossly normal, gait intact SKIN: warm and well perfused, no excoriations or lesions, no rashes exam on discharge: Physical exam: VS: T 97.4 BP 144/80 HR 102 RR 22 O2 sat 93%2L GENERAL: Patient is sitting up in bed, responsive to voice, no apparent distress HEENT: PERRL, no scleral icterus, dry mucous membranes LUNGS: mild crackles, wheezing, and rhonchi bilaterally HEART: Normal S1S2, tachycardic, no murmurs rubs or gallops ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: Warm, well-perfused, no lower extremity edema NEURO: A&Ox3, [MASKED] strength in upper extremities bilaterally CNII-XII intact, [MASKED] motor strength in bilateral upper extremities. ACCESS: PICC line LUE Pertinent Results: ADMISSION: =========== [MASKED] 10:10PM [MASKED] PO2-70* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 [MASKED] 09:26PM URINE HOURS-RANDOM [MASKED] 09:26PM URINE HOURS-RANDOM [MASKED] 09:26PM URINE HOURS-RANDOM [MASKED] 09:26PM URINE UHOLD-HOLD [MASKED] 09:26PM URINE GR HOLD-HOLD [MASKED] 09:00PM [MASKED] PO2-67* PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 [MASKED] 09:00PM LACTATE-3.6* [MASKED] 08:45PM GLUCOSE-130* UREA N-20 CREAT-0.6 SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 [MASKED] 08:45PM ALT(SGPT)-48* AST(SGOT)-39 LD(LDH)-290* ALK PHOS-153* TOT BILI-1.0 [MASKED] 08:45PM proBNP-329 [MASKED] 08:45PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.9 URIC ACID-3.5 IRON-137 [MASKED] 08:45PM calTIBC-256* FERRITIN-395 TRF-197* [MASKED] 08:45PM WBC-49.6* RBC-5.42 HGB-17.5 HCT-49.5 MCV-91 MCH-32.3* MCHC-35.4 RDW-12.9 RDWSD-42.5 [MASKED] 08:45PM NEUTS-75* BANDS-17* LYMPHS-1* MONOS-5 EOS-1 BASOS-0 ATYPS-1* [MASKED] MYELOS-0 AbsNeut-45.63* AbsLymp-0.99* AbsMono-2.48* AbsEos-0.50 AbsBaso-0.00* [MASKED] 08:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [MASKED] 08:45PM PLT SMR-LOW PLT COUNT-129* [MASKED] 08:45PM [MASKED] PTT-24.9* [MASKED] [MASKED] 08:45PM FIBRINOGE-86* [MASKED] 07:54PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 03:00PM HOS-AVAILABLE [MASKED] 01:03PM TYPE-ART PO2-40* PCO2-45 PH-7.34* TOTAL CO2-25 BASE XS--1 [MASKED] 01:03PM GLUCOSE-168* LACTATE-6.0* NA+-127* K+-4.3 CL--92* [MASKED] 01:03PM HGB-18.5* calcHCT-56 O2 SAT-70 CARBOXYHB-1 MET HGB-0 [MASKED] 01:03PM freeCa-1.19 [MASKED] 12:56PM UREA N-24* CREAT-0.8 [MASKED] 12:56PM estGFR-Using this [MASKED] 12:56PM LIPASE-20 [MASKED] 12:56PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 12:56PM WBC-61.3*# RBC-5.53 HGB-17.7*# HCT-51.1* MCV-92 MCH-32.0 MCHC-34.6 RDW-13.1 RDWSD-43.4 [MASKED] 12:56PM NEUTS-66 BANDS-25* LYMPHS-1* MONOS-2* EOS-0 BASOS-1 [MASKED] METAS-2* MYELOS-3* AbsNeut-55.78* AbsLymp-0.61* AbsMono-1.23* AbsEos-0.00* AbsBaso-0.61* [MASKED] 12:56PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [MASKED] 12:56PM PLT SMR-NORMAL PLT COUNT-155 [MASKED] 12:56PM [MASKED] PTT-27.5 [MASKED] [MASKED] 12:56PM [MASKED] [MASKED] 05:24AM BLOOD WBC-7.6 RBC-2.38* Hgb-7.6* Hct-23.1* MCV-97 MCH-31.9 MCHC-32.9 RDW-14.0 RDWSD-44.0 Plt [MASKED] [MASKED] 02:15PM BLOOD Neuts-68.1 Lymphs-16.6* Monos-12.5 Eos-2.0 Baso-0.4 Im [MASKED] AbsNeut-3.70 AbsLymp-0.90* AbsMono-0.68 AbsEos-0.11 AbsBaso-0.02 [MASKED] 12:52AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [MASKED] 06:39AM BLOOD H/O Smr-AVAILABLE [MASKED] 08:38AM BLOOD [MASKED] [MASKED] 05:24AM BLOOD Glucose-121* UreaN-13 Creat-0.5 Na-140 K-4.1 Cl-99 HCO3-31 AnGap-14 [MASKED] 02:15PM BLOOD Ret Aut-0.5 Abs Ret-0.01* [MASKED] 05:24AM BLOOD estGFR-Using this [MASKED] 03:57AM BLOOD CK(CPK)-62 [MASKED] 05:49PM BLOOD CK-MB-4 cTropnT-0.01 [MASKED] 05:24AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 [MASKED] 02:15PM BLOOD VitB12-982* Hapto-66 [MASKED] 02:12AM BLOOD Triglyc-147 [MASKED] 06:39AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* [MASKED] 02:12AM BLOOD IgG-571* IgA-179 IgM-56 [MASKED] 12:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:31PM BLOOD HoldBLu-HOLD [MASKED] 10:36AM BLOOD [MASKED] pO2-98 pCO2-54* pH-7.32* calTCO2-29 Base XS-0 Comment-GREEN TOP [MASKED] 10:36AM BLOOD Lactate-1.6 [MASKED] 09:23AM BLOOD O2 Sat-83 [MASKED] 09:40PM BLOOD freeCa-1.15 [MASKED] 08:45PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [MASKED] 05:24AM BLOOD WBC-7.6 RBC-2.38* Hgb-7.6* Hct-23.1* MCV-97 MCH-31.9 MCHC-32.9 RDW-14.0 RDWSD-44.0 Plt [MASKED] [MASKED] Imaging VIDEO OROPHARYNGEAL SWA Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration but there was penetration with thin and nectar thick liquids. Moderate to large amount of residue is noted in the piriform sinuses. HEST W/O CONTRAST 1. Interval improvement in previously seen diffuse bilateral multifocal consolidations, centrilobular nodules, and mediastinal lymphadenopathy since the prior exam in [MASKED], compatible with improving infection. 2. Multifocal bronchiectasis is more prominent.. 3. Small layering left pleural effusion. [MASKED] Imaging CHEST (PORTABLE AP) Comparison to [MASKED]. The widespread bilateral parenchymal opacities have minimally decreased in extent and severity but are still clearly visible, predominating in the right upper lobe, left upper lobe and left lower lobe. The size of the cardiac silhouette is unchanged. Stable monitoring and support devices. [MASKED] Cardiovascular ECG Sinus tachycardia with frequent premature atrial complexes. Non-diagnostic Q waves inferiorly. Non-specific ST segment changes. Compared to the previous tracing of [MASKED] the ventricular rate is slightly faster and ventricular ectopy is no longer appreciated. Atrial ectopy is new. A short burst of a narrow complex tachycardia is no longer evident. [MASKED] Imaging CT HEAD W/O CONTRAST There is no evidence of infarction, hemorrhage, edema, or mass. There are mild chronic small vessel ischemic changes. There is generalized brain parenchymal atrophy. There is no evidence of fracture. There is fluid in the paranasal sinuses, mastoids, right middle ear, likely related to intubation. The visualized portion of the orbits are unremarkable. [MASKED] SPUTUM GRAM STAIN (Final [MASKED]: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. MTB Direct Amplification (Final [MASKED]: CANCELLED. Specimen received less than 7 days from previous testing. PATIENT CREDITED. Reported to and read back by [MASKED] @ 09:00, [MASKED]. LABS ON THE DAY OF DISCHARGE: ============================= [MASKED] 06:24AM BLOOD WBC-5.9 RBC-2.69* Hgb-9.0* Hct-27.5* MCV-102* MCH-33.5* MCHC-32.7 RDW-16.6* RDWSD-61.0* Plt [MASKED] [MASKED] 12:52AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Brief Hospital Course: Mr. [MASKED] is an [MASKED] male with longstanding bronchiectasis and recurrent PNA presenting with 1 week of acutely worsening dyspnea, shortness of breath and cough and significant worsening of bronchiectasis with diffuse patchy infiltrates on CT chest, along with a hilar mass and LAD c/f malignancy vs. infection/superinfection, admitted to the MICU for management of septic shock likely secondary to Nocardia pneumonia. #Hypoxemic respiratory failure: #Nocardia PNA #AFB on sputum: Pt arrived to ED dyspneic but on RA, where he triggered for hypoxemia, requiring a NRB. His CT chest showed significant scattered nodular opacities, diffuse GGOs, interval worsening of bronchiectasis, and new hilar LAD and mass concerning for infection vs malignancy. He was admitted to the MICU and placed on high-flow O2, requiring intubation on [MASKED] when he started fatiguing. He was briefly treated empirically with vancomycin and cefepime, then transitioned to Bactrim ([MASKED]) and imipenem-cilastatin when an infectious workup, including bronchoscopy with BAL, revealed GPRs c/f Nocardia infection. Cultures from induced sputum sample from [MASKED] confirmed Nocardia and also grew mycobacterium avium. Of note, he was s/p several workups for TB given concerning findings on imaging, all of which were negative for TB but positive for non-tuberculous mycobacterial infection ([MASKED]) with unclear treatment history. Bactrim was replaced with linezolid ([MASKED]-) given concern for his elevated creatinine. ID followed closely, recommencing a a [MASKED] week course of dual therapy followed by a [MASKED] month course of monotherapy, yet to be determined at discharge from the MICU. Significant volume overload and pulmonary edema resulting from aggressive fluid resuscitation for his septic shock of respiratory origin also contributed to his hypoxia and he required diuresis on a lasix gtt. His respiratory status slowly improved and he was extuabed on [MASKED], then weaned from high-flow to nasal cannula prior to discharge from the medicine floor for continuation of treatment with antibiotics and management of his secretions. Respiratory status remained stable on medical floor, though had intermittent aspiration episodes causing desaturation. On the floor patient stable O2 saturations ranging between [MASKED] on 2 L nasal cannula. He has had evaluation by speech and swallow which showed evidence of aspiration with thin and nectar thick liquids there was also moderate to large amount of residual noted in the piriform sinuses. Due to the risk of aspiration, the patient is advised to remain n.p.o. on tube feeds pending further evaluation in 2 weeks for resolution of his muscle weakness and aspiration. #Septic shock: He developed hypotension with MAPs dropping into the [MASKED], elevated lactate, oliguria, and altered mental status, all in the setting of respiratory infection, requiring pressor support with phenylephrine, then norepinephrine and vasopressin. He was also aggressively fluid resuscitated and was net positive 20L prior to initiation of diuresis for which he required pressor support. A cardiogenic component was considered, particularly given his volume status but an TTE revealed an preserved EF and no regional or global wall motion abnormalities. He was eventually weaned off pressor with stabilization of his BP. On transfer to the floor the patient's blood pressure ranged between 110–150/50s-70s. [MASKED]: His creatinine climbed to 3.7 from baseline of 0.7 with patient becoming oliguric consistent with ATN resulting from hypoperfusion in the setting of shock, with renal injury related to contrast also likely contributing. His urine output increased several days later and he continued to autodiurese with his Cr returning to baseline at discharge from the ICU. On the floor the patient's creatinine continued to trend down to 0.4 on the day of discharge. #Thrombocytopenia: His platelet count was depressed but variable. Nadir was [MASKED], thought secondary to bone marrow suppression from linezolid. Platelets uptrended and were stable on discharge. On the floor patient's platelets continue to improve and were 109 on discharge #Leukocytosis: The patient had a leukocytosis to 61 on admission. Heme/onc was consulted and a peripheral smear was reassuring for no underlying hematologic process. The significant white count was most consistent with a leukamoid reaction in the setting of infection and his WBC count was downtrending to normal by his discharge from the ICU. # Hypernatremia: As high as 150, secondary to poor PO intake, improved after D5W and restarting tube feeds. # weakness: likely from critical illness myopathy which is a reversible condition. His aspiration event are likely from transient muscle weakness which should improve with time. His feeding and oral medication was given through an dobhoff tube. His most recent Speech and swallow eval showed interval improvement. a re-eval in the future is required before removing the dobhoff. the dobhoff was replaced 1 day prior to discharge. #Concern for underlying lung malignancy: The hilar lymphadenopathy and question of mass was concerning for an underlying malignancy. His BAL, however, was neg for malignant cells. No additional tissue was obtained given the more pressing infection and heme/onc recommended outpatient follow-up, including re-imaging, once the acute infectious process had been addressed. Follow-up CT chest revealed decreasing adenopathy, likely consistent with infectious etiology. However malignancy cannot be completely excluded. Therefore outpatient follow-up is recommended with or without biopsy of the lesion when the general condition of this patient improves. #Hypogammaglobulinemia: His IgG was mildly depressed, likely related to consumption. A repeat level is warranted post-infection. #BPH: Both his home finasteride and tamsulosin were held in the setting of brisk urine output in the recovery phase of likely ATN, and then in the setting of an NGT. =========================== Transitional issues: –The patient has anemia and thrombocytopenia a CBC in 1 week is recommended –The patient has significant global weakness, which is likely from critical illness myopathy. He would require further evaluation as an outpatient. Neurology evaluation may be as an outpatient. –The patient has significant muscle weakness resulting in aspiration with positive video swallow test. This weakness is likely temporary from critical illness myopathy. However, neurological causes cannot be excluded. Further evaluation with speech and swallow should continue. Also further evaluation by physical therapy is required. The patient might need speech therapy to improve swallowing ability safely. –Nocardia pneumonia with underlying bronchiectasis was identified on admission. Continue imipenem and minocycline until [MASKED]. At the time of discharge Nocardia sensitivities were pending. –The patient will require IV antibiotic titration or change based on the cardia sensitivities. –The patient has a lung nodule discovered on CT on [MASKED] concerning for lung malignancy. However, seems to be interval improvement on CT on [MASKED]. Although infection is a most likely diagnosis, malignancy cannot be excluded. A biopsy might be needed. -The patient was started on bisacodyl, imipenem cilastatin, polyethylene glycol, senna on discharge. –we stopped the patient's levofloxacin, loratadine, lorazepam, naproxen, finasteride. CODE STATUS: Full code. Contact: Wife, [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Naproxen 500 mg PO [MASKED] DAILY PRN Pain - Mild 2. LORazepam 0.5 mg PO QHS:PRN insomnia 3. Docusate Sodium 100 mg PO BID 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q6H 6. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eye 7. Loratadine 10 mg PO DAILY 8. TraZODone 50 mg PO QHS:PRN insomnia 9. Finasteride 5 mg PO DAILY 10. Tamsulosin 0.4 mg PO DAILY 11. Levofloxacin 500 mg PO Q24H Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. GuaiFENesin [MASKED] mL PO Q6H:PRN cough 3. imipenem-cilastatin 500 mg IV Q6H 4. Minocycline 100 mg IV BID 5. Polyethylene Glycol 17 g PO DAILY:PRN contipation 6. Senna 17.2 mg PO BID:PRN constipation 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Albuterol Inhaler 2 PUFF IH Q6H 9. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eye 10. Docusate Sodium 100 mg PO BID 11. Finasteride 5 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: Nocardia pneumonia Secondary Diagnosis: Aspiration Oropharyngeal dysphagia Anemia Discharge Condition: Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure treating you at [MASKED]! Why was I admitted to the hospital? -You were admitted because you were having trouble breathing, and we found that you had an infection. What happened while I was in the hospital? -We treated your infection in your lungs with antibiotics. -For some time you needed a breathing tube to help you breathe, which was removed. -You had difficulty swallowing and eating food, so we placed a feeding tube to help you get nutrition. What should I do when I am discharged? -Please continue your follow-up with your Infectious Disease doctors. -[MASKED] continue working with physical therapy to get your strength back. We wish you the best! Your [MASKED] care providers [MASKED]: [MASKED]
[]
[ "J9601", "Y92230", "N400" ]
[ "A419: Sepsis, unspecified organism", "G9341: Metabolic encephalopathy", "N170: Acute kidney failure with tubular necrosis", "J9601: Acute respiratory failure with hypoxia", "D65: Disseminated intravascular coagulation [defibrination syndrome]", "R6521: Severe sepsis with septic shock", "J690: Pneumonitis due to inhalation of food and vomit", "E43: Unspecified severe protein-calorie malnutrition", "R1312: Dysphagia, oropharyngeal phase", "G7281: Critical illness myopathy", "E870: Hyperosmolality and hypernatremia", "A430: Pulmonary nocardiosis", "I471: Supraventricular tachycardia", "D801: Nonfamilial hypogammaglobulinemia", "C3401: Malignant neoplasm of right main bronchus", "D6959: Other secondary thrombocytopenia", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "T370X5A: Adverse effect of sulfonamides, initial encounter", "D638: Anemia in other chronic diseases classified elsewhere", "E861: Hypovolemia", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "J479: Bronchiectasis, uncomplicated", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "E875: Hyperkalemia", "E8770: Fluid overload, unspecified" ]
10,064,854
27,887,452
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: ___ - Closed Reduction and Percutaneous Pinning of R Femoral Neck History of Present Illness: ___ year-old ___ speaking male with a PMHx significant for long-standing bronchiectasis and hospitalization (___) for severe pulmonary infection of Nocardia and MAC who presents to the hospital with 3 weeks of right hip pain after suffering a fall at home. The history outlined below was obtained through ___ interpretation services over the phone overnight. The patient does not recall the exact events of his fall though thinks he hit his head at that time. He is unable to recall whether he had preceding palpitations, lightheadedness, difficulty breathing, or presyncopal symptoms. The patient endorses using a walker or cane at baseline secondary to bilateral hip pain, however over the last 3 weeks since his fall onto the right-hand side he has had persistent right hip pain that his force him to now use a wheelchair for ambulation. He endorses pain with all weightbearing activities with the right lower extremity. Initial x-rays of the pelvis and right femur obtained by the emergency department today were initially concerning for cortical irregularity of the lateral margin of the right basicervical junction, however full trauma imaging workup was revealing for nondisplaced basicervical fracture of the right femur. Of note patient's CT of the C-spine, head, and lumbar spine were negative for acute traumatic injury. Chest x-ray notable for chronic scarring and emphysema also appreciated on previous chest CT. Patient denies any numbness, tingling, weakness of the right lower extremity. He denies prior loss of consciousness related to his fall 3 weeks ago. He denies pain or injury elsewhere. Past Medical History: PULMONARY NODULE ABNORMAL CHEST CT SCAN R Hip fracture Social History: ___ Family History: Non-contributory Physical Exam: General: awake, alert, no acute distress, resting comfortably in bed Cardio: regular rate and rhythm, 72 bpm by radial palpation at time of exam Pulmonary: no increased work of breathing MSK: RLE: Surgical dressing is clean, dry, and intact, there is no surrounding erythema or induration Able to fire: FHL, ___, TA, GSC on command Sensation intact to light touch on most recent exam with interpreter ___ afternoon) 2+ DP pulse Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right femoral neck fracture. Given his progressive pain, decreased functionality, and the operative nature of his injury, L discussion was had with the patient using an interpreter regarding the risk and benefit of the surgery. After discussing the operation with his family he understood not only the risks, but also the benefits that he could expect from this operation. He was then admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for closed reduction and percutaneous pinning of the right femoral neck, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. Despite narcotic medications being made available to him, he manage his pain control with only acetaminophen. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to **** was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the right lower extremity, and will be discharged on 40 mg of enoxaparin for DVT prophylaxis. He will take this medication for a total of 1 month the date of his surgery. The expected end date of this medication is ___. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 25 mcg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Finasteride 5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY Do not exceed 4000mg of acetaminophen (Tylenol) total, daily. 2. Docusate Sodium 100 mg PO BID Take while you are using your narcotic pain medications. 3. Enoxaparin Sodium 40 mg SC QHS Expected end date of this medcication is ___. RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*30 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate Do not drink or drive on this medication. Beware sedation. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4h Disp #*15 Tablet Refills:*0 5. Finasteride 5 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated and range of motion as tolerated in the right lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take 40 mg of enoxaparin subcutaneously daily for 4 weeks total from the date of the operation. The expected end date of this medication is ___. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: Weight bearing as tolerated and range of motion as tolerated in the right lower extremity. Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: ___
[ "S72091A", "W1830XA", "J449", "E039", "N400", "Z87891", "Y92099", "R001" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: [MASKED] - Closed Reduction and Percutaneous Pinning of R Femoral Neck History of Present Illness: [MASKED] year-old [MASKED] speaking male with a PMHx significant for long-standing bronchiectasis and hospitalization ([MASKED]) for severe pulmonary infection of Nocardia and MAC who presents to the hospital with 3 weeks of right hip pain after suffering a fall at home. The history outlined below was obtained through [MASKED] interpretation services over the phone overnight. The patient does not recall the exact events of his fall though thinks he hit his head at that time. He is unable to recall whether he had preceding palpitations, lightheadedness, difficulty breathing, or presyncopal symptoms. The patient endorses using a walker or cane at baseline secondary to bilateral hip pain, however over the last 3 weeks since his fall onto the right-hand side he has had persistent right hip pain that his force him to now use a wheelchair for ambulation. He endorses pain with all weightbearing activities with the right lower extremity. Initial x-rays of the pelvis and right femur obtained by the emergency department today were initially concerning for cortical irregularity of the lateral margin of the right basicervical junction, however full trauma imaging workup was revealing for nondisplaced basicervical fracture of the right femur. Of note patient's CT of the C-spine, head, and lumbar spine were negative for acute traumatic injury. Chest x-ray notable for chronic scarring and emphysema also appreciated on previous chest CT. Patient denies any numbness, tingling, weakness of the right lower extremity. He denies prior loss of consciousness related to his fall 3 weeks ago. He denies pain or injury elsewhere. Past Medical History: PULMONARY NODULE ABNORMAL CHEST CT SCAN R Hip fracture Social History: [MASKED] Family History: Non-contributory Physical Exam: General: awake, alert, no acute distress, resting comfortably in bed Cardio: regular rate and rhythm, 72 bpm by radial palpation at time of exam Pulmonary: no increased work of breathing MSK: RLE: Surgical dressing is clean, dry, and intact, there is no surrounding erythema or induration Able to fire: FHL, [MASKED], TA, GSC on command Sensation intact to light touch on most recent exam with interpreter [MASKED] afternoon) 2+ DP pulse Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right femoral neck fracture. Given his progressive pain, decreased functionality, and the operative nature of his injury, L discussion was had with the patient using an interpreter regarding the risk and benefit of the surgery. After discussing the operation with his family he understood not only the risks, but also the benefits that he could expect from this operation. He was then admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for closed reduction and percutaneous pinning of the right femoral neck, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. Despite narcotic medications being made available to him, he manage his pain control with only acetaminophen. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to **** was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the right lower extremity, and will be discharged on 40 mg of enoxaparin for DVT prophylaxis. He will take this medication for a total of 1 month the date of his surgery. The expected end date of this medication is [MASKED]. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 25 mcg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Finasteride 5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY Do not exceed 4000mg of acetaminophen (Tylenol) total, daily. 2. Docusate Sodium 100 mg PO BID Take while you are using your narcotic pain medications. 3. Enoxaparin Sodium 40 mg SC QHS Expected end date of this medcication is [MASKED]. RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*30 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate Do not drink or drive on this medication. Beware sedation. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4h Disp #*15 Tablet Refills:*0 5. Finasteride 5 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: R femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated and range of motion as tolerated in the right lower extremity MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take 40 mg of enoxaparin subcutaneously daily for 4 weeks total from the date of the operation. The expected end date of this medication is [MASKED]. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: Weight bearing as tolerated and range of motion as tolerated in the right lower extremity. Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: [MASKED]
[]
[ "J449", "E039", "N400", "Z87891" ]
[ "S72091A: Other fracture of head and neck of right femur, initial encounter for closed fracture", "W1830XA: Fall on same level, unspecified, initial encounter", "J449: Chronic obstructive pulmonary disease, unspecified", "E039: Hypothyroidism, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z87891: Personal history of nicotine dependence", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "R001: Bradycardia, unspecified" ]
10,065,024
25,406,025
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - 1. Coronary artery bypass graft x 3. Total arterial revascularization. 2. Skeletonized left internal mammary artery graft to left anterior descending artery. 3. Left radial artery sequential grafting to ramus and obtuse marginal artery. 4. Endoscopic harvesting of the left radial artery. History of Present Illness: ___ year old male with past medical history of hypertension, hyperlipidemia, and diabetes mellitus type 2 who has had chest pain that radiates to both arms after eating, and sometimes at rest. It first started about ___ ago. He also has experienced dyspnea with mild exertion for the past month. Stress test ___ suggestive of inferolateral ischemia. His beta blocker was increased with the hope of improving his symptoms which was unsuccessful. He was referred for cardiac catheterization which he underwent today and it demonstrated three-vessel coronary artery disease. He was transferred to ___ for coronary artery bypass graft evaluation. Past Medical History: hypertension hyperlipidemia Diabetes mellitus type 2 Pericarditis about ___ yrs ago left foot drop from injury to left after a fall, wears a brace PRN Social History: ___ Family History: Mother- ___ and CAD Sister- ___ Brother- ___ Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: 70 in Weight: 196 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds + []tender firm lower abd- Extremities: Warm [x], well-perfused [x] Edema []none _____ Varicosities: None [] Neuro: Grossly intact [] Pulses: Femoral Right: +2 Left:+2 DP Right: trace Left:trace ___ Right:trace Left:trace Radial Right: cath site Left:+2 Carotid Bruit: Right: - Left:- Discharge Physical Examination: General: NAD [x] Neurological: A/O x3 [x] Moves all extremities [x] Cardiovascular: RRR [x] Irregular [] Murmur [] Respiratory: CTA [x] No resp distress [x] GU/Renal: Urine clear [x] GI/Abdomen: Bowel sounds hypoactive [x] Softly distended [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema Left Upper extremity Warm [x] Edema Right Lower extremity Warm [x] Edema tr Left Lower extremity Warm [x] Edema tr Pulses: DP Right: + Left:+ ___ Right: + Left:+ Radial Right: + Left:RAG Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Lower extremity: Right [] Left [] CDI [] Left foot drop (baseline) Upper extremity: Right [] Left [x] CDI [x] Pertinent Results: ___ ECHO PRE-OPERATIVE STATE: Pre-bypass assessment. Left Atrium ___ Veins: Normal ___ size. No spontaneous echo contrast is seen in the ___. No ___ mass/thrombus. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Normal RA size. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Normal cavity size. Aorta: Normal sinus diameter. Mild ascending dilation. Normal descending aorta diameter. No sinus atheroma. No ascending atheroma.No arch atheroma. No descending atheroma. Aortic Valve: Thin/mobile (3) leaflets. Minimal leaflet calcification. Trace regurgitation. Mitral Valve: Normal leaflets. No stenosis. Mild annular calcification. Mild [1+] regurgitation. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. POST-OP STATE: The post-bypass TEE was performed at 16:26:00. Left Ventricle: Similar to preoperative findings. SImilar regional function. Global ejection fraction is normal. Right Ventricle: No change in systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. No change in aortic regurgitation. Mitral Valve: No change in mitral valve morphology from preoperative state. No change in valvular regurgitation from preoperative state. Pericardium: No effusion. Notification: The surgeon/proceduralist was notified of the findings at the time of the study. ___ 08:55AM BLOOD WBC-11.0* ___ 10:50AM BLOOD WBC-13.2* RBC-3.35* Hgb-10.9* Hct-31.6* MCV-94 MCH-32.5* MCHC-34.5 RDW-12.7 RDWSD-43.3 Plt ___ ___ 01:45AM BLOOD ___ PTT-27.6 ___ ___ 06:24PM BLOOD WBC-8.8 RBC-4.57* Hgb-14.8 Hct-41.9 MCV-92 MCH-32.4* MCHC-35.3 RDW-12.5 RDWSD-41.0 Plt ___ ___ 06:24PM BLOOD ___ PTT-27.6 ___ ___ 08:55AM BLOOD UreaN-21* Creat-1.0 K-4.5 ___ 10:50AM BLOOD Glucose-175* UreaN-17 Creat-1.1 Na-139 K-4.3 Cl-100 HCO3-29 AnGap-10 ___ 06:24PM BLOOD Glucose-162* UreaN-13 Creat-1.0 Na-142 K-4.0 Cl-107 HCO3-21* AnGap-14 Brief Hospital Course: Mr. ___ was admitted to the ___ on ___ for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner. On ___ he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Precedex was used and on postoperative day one he was extubated. He weaned off of pressor support. Beta-blocker/ASA/Statin and diuresis was initiated. He failed to void and a foley was reinserted. Flomax was started. On postoperative day 2, he was transferred to the step down unit for further recovery. Chest tubes and pacing wires were discontinued per protocol without incident. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The remainder of his hospital course was essentially uneventful. By the time of pod# 4 he was ambulating with assistance, pain controlled, and wounds healing. He was discharged to ___ & Rehab with appropriate follow up advised. Medications on Admission: Aspirin 81 mg daily atorvastatin 20 mg bid folic acid ___ mcg daily glimepiride 4 mg BID green tea leaf extract 1 capsule daily losartan 50 mg daily metformin XR 1000mg bid metoprolol XL 50 mg daily Tamsulosin 0.4 mg daily nitroglycerin 0.4 mg SL prn ___ ___ b12 Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Furosemide 10 mg PO DAILY x 7 days 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Duration: 6 Months x 6 months 9. LORazepam 0.5 mg PO Q8H:PRN anxiety 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Metoprolol Tartrate 75 mg PO TID 12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 h prn Disp #*15 Tablet Refills:*0 13. Polyethylene Glycol 17 g PO DAILY 14. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days x 7 days 15. Ranitidine 150 mg PO BID 16. Senna 17.2 mg PO BID 17. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: CAD hypertension hyperlipidemia Diabetes mellitus type 2 Pericarditis about ___ yrs ago left foot drop from injury to left after a fall, wears a brace PRN Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___
[ "I2510", "D62", "I10", "E785", "E119", "R339", "Z794" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] - 1. Coronary artery bypass graft x 3. Total arterial revascularization. 2. Skeletonized left internal mammary artery graft to left anterior descending artery. 3. Left radial artery sequential grafting to ramus and obtuse marginal artery. 4. Endoscopic harvesting of the left radial artery. History of Present Illness: [MASKED] year old male with past medical history of hypertension, hyperlipidemia, and diabetes mellitus type 2 who has had chest pain that radiates to both arms after eating, and sometimes at rest. It first started about [MASKED] ago. He also has experienced dyspnea with mild exertion for the past month. Stress test [MASKED] suggestive of inferolateral ischemia. His beta blocker was increased with the hope of improving his symptoms which was unsuccessful. He was referred for cardiac catheterization which he underwent today and it demonstrated three-vessel coronary artery disease. He was transferred to [MASKED] for coronary artery bypass graft evaluation. Past Medical History: hypertension hyperlipidemia Diabetes mellitus type 2 Pericarditis about [MASKED] yrs ago left foot drop from injury to left after a fall, wears a brace PRN Social History: [MASKED] Family History: Mother- [MASKED] and CAD Sister- [MASKED] Brother- [MASKED] Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: 70 in Weight: 196 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds + []tender firm lower abd- Extremities: Warm [x], well-perfused [x] Edema []none [MASKED] Varicosities: None [] Neuro: Grossly intact [] Pulses: Femoral Right: +2 Left:+2 DP Right: trace Left:trace [MASKED] Right:trace Left:trace Radial Right: cath site Left:+2 Carotid Bruit: Right: - Left:- Discharge Physical Examination: General: NAD [x] Neurological: A/O x3 [x] Moves all extremities [x] Cardiovascular: RRR [x] Irregular [] Murmur [] Respiratory: CTA [x] No resp distress [x] GU/Renal: Urine clear [x] GI/Abdomen: Bowel sounds hypoactive [x] Softly distended [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema Left Upper extremity Warm [x] Edema Right Lower extremity Warm [x] Edema tr Left Lower extremity Warm [x] Edema tr Pulses: DP Right: + Left:+ [MASKED] Right: + Left:+ Radial Right: + Left:RAG Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Lower extremity: Right [] Left [] CDI [] Left foot drop (baseline) Upper extremity: Right [] Left [x] CDI [x] Pertinent Results: [MASKED] ECHO PRE-OPERATIVE STATE: Pre-bypass assessment. Left Atrium [MASKED] Veins: Normal [MASKED] size. No spontaneous echo contrast is seen in the [MASKED]. No [MASKED] mass/thrombus. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Normal RA size. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Normal cavity size. Aorta: Normal sinus diameter. Mild ascending dilation. Normal descending aorta diameter. No sinus atheroma. No ascending atheroma.No arch atheroma. No descending atheroma. Aortic Valve: Thin/mobile (3) leaflets. Minimal leaflet calcification. Trace regurgitation. Mitral Valve: Normal leaflets. No stenosis. Mild annular calcification. Mild [1+] regurgitation. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. POST-OP STATE: The post-bypass TEE was performed at 16:26:00. Left Ventricle: Similar to preoperative findings. SImilar regional function. Global ejection fraction is normal. Right Ventricle: No change in systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. No change in aortic regurgitation. Mitral Valve: No change in mitral valve morphology from preoperative state. No change in valvular regurgitation from preoperative state. Pericardium: No effusion. Notification: The surgeon/proceduralist was notified of the findings at the time of the study. [MASKED] 08:55AM BLOOD WBC-11.0* [MASKED] 10:50AM BLOOD WBC-13.2* RBC-3.35* Hgb-10.9* Hct-31.6* MCV-94 MCH-32.5* MCHC-34.5 RDW-12.7 RDWSD-43.3 Plt [MASKED] [MASKED] 01:45AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 06:24PM BLOOD WBC-8.8 RBC-4.57* Hgb-14.8 Hct-41.9 MCV-92 MCH-32.4* MCHC-35.3 RDW-12.5 RDWSD-41.0 Plt [MASKED] [MASKED] 06:24PM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 08:55AM BLOOD UreaN-21* Creat-1.0 K-4.5 [MASKED] 10:50AM BLOOD Glucose-175* UreaN-17 Creat-1.1 Na-139 K-4.3 Cl-100 HCO3-29 AnGap-10 [MASKED] 06:24PM BLOOD Glucose-162* UreaN-13 Creat-1.0 Na-142 K-4.0 Cl-107 HCO3-21* AnGap-14 Brief Hospital Course: Mr. [MASKED] was admitted to the [MASKED] on [MASKED] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner. On [MASKED] he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Precedex was used and on postoperative day one he was extubated. He weaned off of pressor support. Beta-blocker/ASA/Statin and diuresis was initiated. He failed to void and a foley was reinserted. Flomax was started. On postoperative day 2, he was transferred to the step down unit for further recovery. Chest tubes and pacing wires were discontinued per protocol without incident. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The remainder of his hospital course was essentially uneventful. By the time of pod# 4 he was ambulating with assistance, pain controlled, and wounds healing. He was discharged to [MASKED] & Rehab with appropriate follow up advised. Medications on Admission: Aspirin 81 mg daily atorvastatin 20 mg bid folic acid [MASKED] mcg daily glimepiride 4 mg BID green tea leaf extract 1 capsule daily losartan 50 mg daily metformin XR 1000mg bid metoprolol XL 50 mg daily Tamsulosin 0.4 mg daily nitroglycerin 0.4 mg SL prn [MASKED] [MASKED] b12 Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Furosemide 10 mg PO DAILY x 7 days 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Duration: 6 Months x 6 months 9. LORazepam 0.5 mg PO Q8H:PRN anxiety 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Metoprolol Tartrate 75 mg PO TID 12. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth q 4 h prn Disp #*15 Tablet Refills:*0 13. Polyethylene Glycol 17 g PO DAILY 14. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days x 7 days 15. Ranitidine 150 mg PO BID 16. Senna 17.2 mg PO BID 17. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: CAD hypertension hyperlipidemia Diabetes mellitus type 2 Pericarditis about [MASKED] yrs ago left foot drop from injury to left after a fall, wears a brace PRN Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [MASKED]
[]
[ "I2510", "D62", "I10", "E785", "E119", "Z794" ]
[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "R339: Retention of urine, unspecified", "Z794: Long term (current) use of insulin" ]
10,065,057
21,928,958
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Unwitnessed fall Major Surgical or Invasive Procedure: 1. Intubation for MRI (___), pacemaker inactivation History of Present Illness: ___ with long history of multiple falls and multiple resulting fractures, lives in group home due to cognitive delay, now presents to ___ in transfer from ___ after having a fall at ~8pm. Her fall was not witnessed. Unknown LOC. Was found by staff who heard her yelling for help. Patient is unable to give a description of the fall, cannot explain the surrounding events, and per her group home worker who accompanied her to the ED this is about baseline. Trauma surgery is now consulted. Past Medical History: Mental retardation Right hip replacement Pelvic fracture Depression Frequent falls with left hip fracture and replacement Herpes zoster Social History: ___ Family History: Mother: CHF, ___ Brother: MI (___) Brother: valvular disease Multiple family members with cardiovascular disease and HLD Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: Temp 98.0 BP 150 / 72 HR 78 RR 18 PO2 93 Ra Physical exam: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended, normal bs. Ext: No edema, warm well-perfused Pertinent Results: ADMISSION LABS: ___ 02:40AM BLOOD WBC-15.0* RBC-3.75* Hgb-11.6 Hct-36.1 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.7 RDWSD-48.0* Plt ___ ___ 02:40AM BLOOD Neuts-87.9* Lymphs-5.3* Monos-5.8 Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.14* AbsLymp-0.80* AbsMono-0.87* AbsEos-0.00* AbsBaso-0.01 ___ 02:40AM BLOOD Glucose-128* UreaN-12 Creat-0.4 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-12 ___ 02:40AM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 ___ 02:52AM BLOOD Glucose-128* Creat-0.4 Na-136 K-3.6 Cl-103 calHCO3-24 DISCHARGE LABS: RADIOLOGY: MRI Head, ___: IMPRESSION: 1. Study is mildly degraded by motion. 2. Question approximately 1 mm left parietal subdural hemorrhage versus artifact, as described. 3. Punctate left precentral gyrus foci of chronic blood products versus mineralization. 4. Previously demonstrated hyperdensity within the right perimesencephalic cistern not definitely seen on current study. Question interval redistribution of blood products. 5. 5 mm left parietal subgaleal hematoma. 6. Interval progression in size of previously noted parotid mass, now measuring up to 2.5 cm, compared to ___ prior exam. 7. Global volume loss and probable microangiopathic changes as described. 8. Paranasal sinus disease and minimal bilateral nonspecific mastoid fluid, as described. MRI C, T Spine, ___: IMPRESSION: 1. Study is degraded by motion and limited by patient positioning. 2. Abnormal fluid signal with effacement of the central inferior endplate of the L3 vertebral body as described, with no definite peripherally enhancing collection. While findings are suggestive of acute Schmorl's node, differential considerations of phlegmonous change or early discitis osteomyelitis is not excluded on the basis ex of this amination. Recommend follow-up imaging to resolution. 3. Acute to subacute L5 vertebral body fracture, as described. 4. Central and vertically oriented fracture through the sacrum, which is incompletely evaluated. A dedicated sacral MR can be considered if further characterization is warranted. 5. Anterior height loss of the C7 vertebral body is unchanged since ___. 6. Probable chronic T7 and T8 anterior compression deformities, as described. 7. Multilevel cervical spondylosis as described, most pronounced at C3-4, where there is moderate to severe vertebral canal, mild left and moderate right neural foraminal narrowing. 8. Additional multilevel thoracic and lumbar spine spondylosis as described without definite evidence of moderate or severe vertebral canal narrowing. 9. Within limits of study, no definite evidence of spinal cord lesion. Multilevel spinal cord probable remodeling as described. 10. Small bilateral pleural effusions as described. If clinically indicated, consider correlation with dedicated chest imaging. 11. Cholelithiasis. 12. Known right parotid cystic mass better characterized on same day brain MR. 13. Please see concurrently obtained brain MRI for description of cranial structures. Brief Hospital Course: Ms. ___ was admitted to the ___ ___ after ___. Her injuries included: a small subarachnoid hemorrhage, left superior and inferior pubic rami fractures, acute L5 vertebral body fracture and multiple left sided rib fractures. On admission she was given a regular diet. Orthopedics was consulted and recommended weight bearing as tolerated to both her lower extremities and a walker as needed. In terms of the subarachnoid hemorrhage, neurosurgery was consulted and recommended TBI pathway, starting subcutaneous heparin 24 hours after admission, and aspirin on ___ which occurred. Spine was also consulted due to a series of findings on the CT spine that were of uncertain chronicity and recommended an MRI. She was bedrest with a hard cervical collar until the MRI occurred. A great deal of care coordination was spent to schedule the MRI due to the need for intubation (given her baseline cognitive delay) and electrophysiology was involved for the pacemaker. She finally got the MRI on ___ which revealed only an acute L5 vertebral body fracture. Per neurosurgery's recommendations, the cervical collar was removed, the patient was liberalized and got out of bed and her diet was advanced to a regular diet. Her foley catheter was discontinued and she voided spontaneously thereafter. She worked with physical therapy on ___ and recommended rehab. She was eventually discharged to a rehabilitation facility on ___. She voiced understanding of the discharge plan and appropriate follow up was set in place, Of note the MRI of her head did note a small right parotid mass that was slightly increased compared to prior which will need to be followed up as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO QPM 2. Aspirin 325 mg PO DAILY 3. Vitamin D 800 UNIT PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 6. Bisacodyl ___AILY 7. PredniSONE 15 mg PO DAILY 8. Acetaminophen 650 mg PO Q8H Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY Please hold for loose stools 2. Senna 17.2 mg PO HS Please hold for loose stools 3. TraMADol 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 4. Acetaminophen 1000 mg PO TID 5. Docusate Sodium 100 mg PO BID 6. Aspirin 325 mg PO DAILY 7. Bisacodyl ___AILY 8. Pravastatin 40 mg PO QPM 9. PredniSONE 15 mg PO DAILY 10. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Subarachnoid hemorrhage 2. Left superior and inferior pubic rami fractures 3. Acute L5 vertebral body fracture 4. Left sided rib fractures 5. Right parotid cystic mass 6. Complete AV block 7. Cognitive delay 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 ___ after you had an unwitnessed fall at your group home, you were found to have a small brain bleed a small pelvic fracture and some new ( and old) rib fractures). You were seen by physical therapy who recommended rehab. You are now stable for discharge to rehab to continue your recovery. Please follow the following instructions to aid in your recovery - You do not need to follow up with neurosurgery, who saw you in the hospital. You may continue your Aspirin 325mg Rib Fractures: * Your injury caused multiple rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. 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. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Best Wishes, Your ___ Surgery Team Followup Instructions: ___
[ "S066X9A", "S2242XA", "S32592A", "S32059A", "W19XXXA", "Y92092", "K118", "Z96641", "Z45018", "Q909", "J449", "M79605", "R079" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Unwitnessed fall Major Surgical or Invasive Procedure: 1. Intubation for MRI ([MASKED]), pacemaker inactivation History of Present Illness: [MASKED] with long history of multiple falls and multiple resulting fractures, lives in group home due to cognitive delay, now presents to [MASKED] in transfer from [MASKED] after having a fall at ~8pm. Her fall was not witnessed. Unknown LOC. Was found by staff who heard her yelling for help. Patient is unable to give a description of the fall, cannot explain the surrounding events, and per her group home worker who accompanied her to the ED this is about baseline. Trauma surgery is now consulted. Past Medical History: Mental retardation Right hip replacement Pelvic fracture Depression Frequent falls with left hip fracture and replacement Herpes zoster Social History: [MASKED] Family History: Mother: CHF, [MASKED] Brother: MI ([MASKED]) Brother: valvular disease Multiple family members with cardiovascular disease and HLD Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: Temp 98.0 BP 150 / 72 HR 78 RR 18 PO2 93 Ra Physical exam: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended, normal bs. Ext: No edema, warm well-perfused Pertinent Results: ADMISSION LABS: [MASKED] 02:40AM BLOOD WBC-15.0* RBC-3.75* Hgb-11.6 Hct-36.1 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.7 RDWSD-48.0* Plt [MASKED] [MASKED] 02:40AM BLOOD Neuts-87.9* Lymphs-5.3* Monos-5.8 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-13.14* AbsLymp-0.80* AbsMono-0.87* AbsEos-0.00* AbsBaso-0.01 [MASKED] 02:40AM BLOOD Glucose-128* UreaN-12 Creat-0.4 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-12 [MASKED] 02:40AM BLOOD cTropnT-<0.01 [MASKED] 05:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 [MASKED] 02:52AM BLOOD Glucose-128* Creat-0.4 Na-136 K-3.6 Cl-103 calHCO3-24 DISCHARGE LABS: RADIOLOGY: MRI Head, [MASKED]: IMPRESSION: 1. Study is mildly degraded by motion. 2. Question approximately 1 mm left parietal subdural hemorrhage versus artifact, as described. 3. Punctate left precentral gyrus foci of chronic blood products versus mineralization. 4. Previously demonstrated hyperdensity within the right perimesencephalic cistern not definitely seen on current study. Question interval redistribution of blood products. 5. 5 mm left parietal subgaleal hematoma. 6. Interval progression in size of previously noted parotid mass, now measuring up to 2.5 cm, compared to [MASKED] prior exam. 7. Global volume loss and probable microangiopathic changes as described. 8. Paranasal sinus disease and minimal bilateral nonspecific mastoid fluid, as described. MRI C, T Spine, [MASKED]: IMPRESSION: 1. Study is degraded by motion and limited by patient positioning. 2. Abnormal fluid signal with effacement of the central inferior endplate of the L3 vertebral body as described, with no definite peripherally enhancing collection. While findings are suggestive of acute Schmorl's node, differential considerations of phlegmonous change or early discitis osteomyelitis is not excluded on the basis ex of this amination. Recommend follow-up imaging to resolution. 3. Acute to subacute L5 vertebral body fracture, as described. 4. Central and vertically oriented fracture through the sacrum, which is incompletely evaluated. A dedicated sacral MR can be considered if further characterization is warranted. 5. Anterior height loss of the C7 vertebral body is unchanged since [MASKED]. 6. Probable chronic T7 and T8 anterior compression deformities, as described. 7. Multilevel cervical spondylosis as described, most pronounced at C3-4, where there is moderate to severe vertebral canal, mild left and moderate right neural foraminal narrowing. 8. Additional multilevel thoracic and lumbar spine spondylosis as described without definite evidence of moderate or severe vertebral canal narrowing. 9. Within limits of study, no definite evidence of spinal cord lesion. Multilevel spinal cord probable remodeling as described. 10. Small bilateral pleural effusions as described. If clinically indicated, consider correlation with dedicated chest imaging. 11. Cholelithiasis. 12. Known right parotid cystic mass better characterized on same day brain MR. 13. Please see concurrently obtained brain MRI for description of cranial structures. Brief Hospital Course: Ms. [MASKED] was admitted to the [MASKED] [MASKED] after [MASKED]. Her injuries included: a small subarachnoid hemorrhage, left superior and inferior pubic rami fractures, acute L5 vertebral body fracture and multiple left sided rib fractures. On admission she was given a regular diet. Orthopedics was consulted and recommended weight bearing as tolerated to both her lower extremities and a walker as needed. In terms of the subarachnoid hemorrhage, neurosurgery was consulted and recommended TBI pathway, starting subcutaneous heparin 24 hours after admission, and aspirin on [MASKED] which occurred. Spine was also consulted due to a series of findings on the CT spine that were of uncertain chronicity and recommended an MRI. She was bedrest with a hard cervical collar until the MRI occurred. A great deal of care coordination was spent to schedule the MRI due to the need for intubation (given her baseline cognitive delay) and electrophysiology was involved for the pacemaker. She finally got the MRI on [MASKED] which revealed only an acute L5 vertebral body fracture. Per neurosurgery's recommendations, the cervical collar was removed, the patient was liberalized and got out of bed and her diet was advanced to a regular diet. Her foley catheter was discontinued and she voided spontaneously thereafter. She worked with physical therapy on [MASKED] and recommended rehab. She was eventually discharged to a rehabilitation facility on [MASKED]. She voiced understanding of the discharge plan and appropriate follow up was set in place, Of note the MRI of her head did note a small right parotid mass that was slightly increased compared to prior which will need to be followed up as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO QPM 2. Aspirin 325 mg PO DAILY 3. Vitamin D 800 UNIT PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 6. Bisacodyl AILY 7. PredniSONE 15 mg PO DAILY 8. Acetaminophen 650 mg PO Q8H Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY Please hold for loose stools 2. Senna 17.2 mg PO HS Please hold for loose stools 3. TraMADol 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 4. Acetaminophen 1000 mg PO TID 5. Docusate Sodium 100 mg PO BID 6. Aspirin 325 mg PO DAILY 7. Bisacodyl AILY 8. Pravastatin 40 mg PO QPM 9. PredniSONE 15 mg PO DAILY 10. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: 1. Subarachnoid hemorrhage 2. Left superior and inferior pubic rami fractures 3. Acute L5 vertebral body fracture 4. Left sided rib fractures 5. Right parotid cystic mass 6. Complete AV block 7. Cognitive delay 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] after you had an unwitnessed fall at your group home, you were found to have a small brain bleed a small pelvic fracture and some new ( and old) rib fractures). You were seen by physical therapy who recommended rehab. You are now stable for discharge to rehab to continue your recovery. Please follow the following instructions to aid in your recovery - You do not need to follow up with neurosurgery, who saw you in the hospital. You may continue your Aspirin 325mg Rib Fractures: * Your injury caused multiple rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. 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. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Best Wishes, Your [MASKED] Surgery Team Followup Instructions: [MASKED]
[]
[ "J449" ]
[ "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "S32592A: Other specified fracture of left pubis, initial encounter for closed fracture", "S32059A: Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y92092: Bedroom in other non-institutional residence as the place of occurrence of the external cause", "K118: Other diseases of salivary glands", "Z96641: Presence of right artificial hip joint", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "Q909: Down syndrome, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "M79605: Pain in left leg", "R079: Chest pain, unspecified" ]
10,065,103
26,907,903
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest burning Major Surgical or Invasive Procedure: ___ - 1. Coronary artery bypass graft x 3, Total arterial revascularization. 2. Skeletonized left internal mammary artery graft to left anterior descending artery. 3. Skeletonized right internal mammary artery graft to obtuse marginal artery. 4. Left radial artery graft to the posterior descending artery. 5. Endoscopic harvesting of the left radial artery. History of Present Illness: Mr. ___ is a ___ year old man with a history of hyperlipidemia and hypertension. Over the last three months he has noted exertional chest pain. He was referred for a stress test which was abnormal. Cardiac catheterization revealed significant left main and multivessel coronary artery disease. He was transferred to ___ for surgical evaluation. Past Medical History: CAD Hyperlipidemia Hypertension Peripheral Neuropathy Social History: ___ Family History: Father died ___ with dementia Mother died ___ with diabetes and renal failure Brother died in his ___- unknown cause Half-brother alive at ___, s/p CABG in his ___ Physical Exam: 97.8 PO 136 / 78 L Sitting 59 18 96 Ra Height: 6' Weight: 279 lb General: NAD, overweight 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 [] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] trace early venous stasis changes; complete left palmar arch based on ___ test Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right: 1+ Left:1+ ___ Right: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit: no bruits Discharge PE: Tmax: 98.9,98.9 BP: 112/66,HR: 75/SR RR:18 O2SAT:93% RA I/O ___ Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [X] Lungs: CTA (X) diminished , No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: no CCE[x] Pulses doppler [] palpable [] Wounds: Sternal: CDI [x] no erythema or drainage [x] ___ 2+ edema. Sternum stable [x] Prevena [x] UE: Right [] Left[x] CDI [x] no erythema or drainage [x] Pertinent Results: Transesophageal Echocardiogram ___ Conclusions PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right 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%). The right ventricle displays normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Dr. ___ was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is in sinus rhythm. There is normal biventricular systolic function. Valvular function is unchanged from the pre-bypass study. The thoracic aorta is intact after decannulation. . ___ 06:40AM BLOOD WBC-9.1 RBC-2.93* Hgb-9.2* Hct-28.3* MCV-97 MCH-31.4 MCHC-32.5 RDW-13.9 RDWSD-49.4* Plt ___ ___ 03:37AM BLOOD ___ PTT-27.3 ___ ___ 06:40AM BLOOD Glucose-110* UreaN-20 Creat-1.0 Na-136 K-4.5 Cl-94* HCO3-28 AnGap-14 ___ 04:10AM BLOOD Glucose-123* UreaN-24* Creat-1.1 Na-132* K-4.2 Cl-92* HCO3-28 AnGap-12 ___ 06:40AM BLOOD Mg-2.3 Brief Hospital Course: He was admitted to ___ on ___. He underwent routine preoperative testing and evaluation. He remained hemodynamically stable and was brought to the perating room on ___. He underwent coronary artery bypass grafting x 3 with total arterial revascularization. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated later that day. He was weaned from inotropic and vasopressor support. Imdur initiated for arterial conduit and should be continued for six months. Beta blocker was initiated and he was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He had a few brief bursts of atrial fibrillation and his beta blocker was uptitrated. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Lisinopril 5 mg PO DAILY 3. Gabapentin 100 mg PO DAILY 4. Baclofen ___ mg PO DAILY:PRN Muscle Spasms 5. amLODIPine 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN pruritis Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs every four (4) hours Disp #*1 Inhaler Refills:*1 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 4. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Duration: 6 Months RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 6. Metoprolol Tartrate 50 mg PO Q8H RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*1 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 9. Ranitidine 150 mg PO BID RX *ranitidine HCl [Heartburn Relief (ranitidine)] 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 12. Aspirin EC 81 mg PO DAILY 13. Atorvastatin 80 mg PO QPM 14. Baclofen ___ mg PO DAILY:PRN Muscle Spasms 15. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN pruritis 16. Gabapentin 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CAD Hypertension Hyperlipidemia ___ neuropathy Past Surgical History: Left knee scope Right rotator cuff tonsillectomy Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - Prevena Trace Edema Discharge Instructions: Prevena instructions · The Prevena Wound dressing should be left on for a total of 7 days post-operatively to receive the full benefit of the therapy. The date of Day # 7 should be written on a piece of tape on the canister to ensure that the nurse from the ___ or Rehab facility knows when to remove the dressing and inspect the incision. If the date is not written, please alert your nurse prior to discharge. · You may shower, however, please avoid getting the dressing and suction canister soiled or saturated. · You will be sent home with a shower bag to hold the suction canister while bathing. · If the dressing does become soiled or saturated, turn the power off and remove the dressing. The entire unit may then be discarded. Should this happen, please notify your ___ nurse, so they may make plans to see you the following day to assess your incision. · Once the Prevena dressing is removed, you may wash your incision daily with a plain white bar soap, such as Dove or ___. Do not apply any creams, lotions or powders to your incision and monitor it daily. · If you notice any redness, swelling or drainage, please contact your surgeon's office at ___. . Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I25119", "G629", "I4891", "I10", "E785", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest burning Major Surgical or Invasive Procedure: [MASKED] - 1. Coronary artery bypass graft x 3, Total arterial revascularization. 2. Skeletonized left internal mammary artery graft to left anterior descending artery. 3. Skeletonized right internal mammary artery graft to obtuse marginal artery. 4. Left radial artery graft to the posterior descending artery. 5. Endoscopic harvesting of the left radial artery. History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of hyperlipidemia and hypertension. Over the last three months he has noted exertional chest pain. He was referred for a stress test which was abnormal. Cardiac catheterization revealed significant left main and multivessel coronary artery disease. He was transferred to [MASKED] for surgical evaluation. Past Medical History: CAD Hyperlipidemia Hypertension Peripheral Neuropathy Social History: [MASKED] Family History: Father died [MASKED] with dementia Mother died [MASKED] with diabetes and renal failure Brother died in his [MASKED]- unknown cause Half-brother alive at [MASKED], s/p CABG in his [MASKED] Physical Exam: 97.8 PO 136 / 78 L Sitting 59 18 96 Ra Height: 6' Weight: 279 lb General: NAD, overweight 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 [] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] trace early venous stasis changes; complete left palmar arch based on [MASKED] test Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right: 1+ Left:1+ [MASKED] Right: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit: no bruits Discharge PE: Tmax: 98.9,98.9 BP: 112/66,HR: 75/SR RR:18 O2SAT:93% RA I/O [MASKED] Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [X] Lungs: CTA (X) diminished , No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: no CCE[x] Pulses doppler [] palpable [] Wounds: Sternal: CDI [x] no erythema or drainage [x] [MASKED] 2+ edema. Sternum stable [x] Prevena [x] UE: Right [] Left[x] CDI [x] no erythema or drainage [x] Pertinent Results: Transesophageal Echocardiogram [MASKED] Conclusions PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right 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%). The right ventricle displays normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Dr. [MASKED] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is in sinus rhythm. There is normal biventricular systolic function. Valvular function is unchanged from the pre-bypass study. The thoracic aorta is intact after decannulation. . [MASKED] 06:40AM BLOOD WBC-9.1 RBC-2.93* Hgb-9.2* Hct-28.3* MCV-97 MCH-31.4 MCHC-32.5 RDW-13.9 RDWSD-49.4* Plt [MASKED] [MASKED] 03:37AM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 06:40AM BLOOD Glucose-110* UreaN-20 Creat-1.0 Na-136 K-4.5 Cl-94* HCO3-28 AnGap-14 [MASKED] 04:10AM BLOOD Glucose-123* UreaN-24* Creat-1.1 Na-132* K-4.2 Cl-92* HCO3-28 AnGap-12 [MASKED] 06:40AM BLOOD Mg-2.3 Brief Hospital Course: He was admitted to [MASKED] on [MASKED]. He underwent routine preoperative testing and evaluation. He remained hemodynamically stable and was brought to the perating room on [MASKED]. He underwent coronary artery bypass grafting x 3 with total arterial revascularization. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated later that day. He was weaned from inotropic and vasopressor support. Imdur initiated for arterial conduit and should be continued for six months. Beta blocker was initiated and he was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He had a few brief bursts of atrial fibrillation and his beta blocker was uptitrated. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Lisinopril 5 mg PO DAILY 3. Gabapentin 100 mg PO DAILY 4. Baclofen [MASKED] mg PO DAILY:PRN Muscle Spasms 5. amLODIPine 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN pruritis Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs every four (4) hours Disp #*1 Inhaler Refills:*1 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 4. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Duration: 6 Months RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 6. Metoprolol Tartrate 50 mg PO Q8H RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*1 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 9. Ranitidine 150 mg PO BID RX *ranitidine HCl [Heartburn Relief (ranitidine)] 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 12. Aspirin EC 81 mg PO DAILY 13. Atorvastatin 80 mg PO QPM 14. Baclofen [MASKED] mg PO DAILY:PRN Muscle Spasms 15. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN pruritis 16. Gabapentin 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: CAD Hypertension Hyperlipidemia [MASKED] neuropathy Past Surgical History: Left knee scope Right rotator cuff tonsillectomy Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - Prevena Trace Edema Discharge Instructions: Prevena instructions · The Prevena Wound dressing should be left on for a total of 7 days post-operatively to receive the full benefit of the therapy. The date of Day # 7 should be written on a piece of tape on the canister to ensure that the nurse from the [MASKED] or Rehab facility knows when to remove the dressing and inspect the incision. If the date is not written, please alert your nurse prior to discharge. · You may shower, however, please avoid getting the dressing and suction canister soiled or saturated. · You will be sent home with a shower bag to hold the suction canister while bathing. · If the dressing does become soiled or saturated, turn the power off and remove the dressing. The entire unit may then be discarded. Should this happen, please notify your [MASKED] nurse, so they may make plans to see you the following day to assess your incision. · Once the Prevena dressing is removed, you may wash your incision daily with a plain white bar soap, such as Dove or [MASKED]. Do not apply any creams, lotions or powders to your incision and monitor it daily. · If you notice any redness, swelling or drainage, please contact your surgeon's office at [MASKED]. . Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "I4891", "I10", "E785", "Z87891" ]
[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "G629: Polyneuropathy, unspecified", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence" ]
10,065,530
25,264,196
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Percocet Attending: ___. Chief Complaint: Mild DOE with Mildly diminished exercise tolerance Major Surgical or Invasive Procedure: ___ Mitral valve repair with a resection of the middle scallop of the posterior leaflet P2, and a Gore- Tex neochordae to the middle scallop of the anterior leaflet A2, and a mitral valve commissuroplasty, mitral valve annuloplasty with a 34 ___ annuloplasty band. History of Present Illness: This is a ___ year old female with known mitral valve disease who has been followed closely with serial echocardiograms. Her most recent echocardiogram from ___ worsening mitral regurgitation due to increased prolapse of the posterior leaflet. She notes that she is highly functional. She participates in spinning, yoga, dancing, and muscle conditioning. She continues to deny any shortness of breath or dyspnea or chest pain with these activities. She does report an increase in palpitations over the last year. She also notes dyspnea with climbing stairs or strong physical exertion. She denies syncope, chest pain, pre-syncope, orthopnea, PND and lower extremity edema. Since her last clinic visit she states that her symptoms have not changed. She is now admitted post-cath for MVR. Past Medical History: - Mitral valve prolapse, Mitral valve insufficiency - Mild Sensorineural hearing loss - Osteoporosis - LAFB (left anterior fascicular block) Past Surgical History: - s/p total abdominal hysterectomy and right salpingo-oophorectomy - Saphenous vein laser ablation bilaterally - Fibroid removal - Right breast cyst removal - hyperplasia Social History: ___ Family History: Father with endocarditis. Brother with CAD. Physical Exam: Admission Exam: Vital Signs 97.7 PO, 131 / 82,98,18,96 Ra General: In NAD Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT, PERRLA [X] EOMI [X], Sclera anicteric, OP benign, No thyromegally Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, Occasional PVC, III/VI systolic murmur best heard at apex. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema [X] Varicosities: Superficial noted. h/o laser ablation. Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 ___ Right:2 Left:2 Radial Right:2 Left:2 Carotid Bruit: None . Discharge Exam: Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [] Lungs: CTA [x] No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: no CCE[] Pulses doppler [] palpable [] 1+ edema Wounds: Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Pertinent Results: ___ Intra-op TEE preliminary report Conclusions Pre-Bypass rhythm: sinus with prequent PVC infusions: phenylephrine 0.2mcg/kg/min 1. The left atrium is mildly dilated. 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. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 3. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. There is moderate/severe P1/P2 and A1/A2 leaflet mitral valve prolapse. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The ___ distance is 2.1 and anterior to posterior leaflet length ratio >1.3. 5. The tricuspid valve leaflets are mildly thickened. Post Bypass rhythm: sinus infusions: phenylephrine 0.6mcg/kg/min 1. Mitral valve with minimal residual regurgitation. There is evidence of intermittent dynamic systolic anterior motion of the anterior mitral valve leaflet. Evidence of aortic valve leaflet fluttering and late systolic closure of aortic valve. Gradient in LVOT >60. Findings discussed at length with cardiac surgeon, decision made to hydrate and slow down heart rate. 2. Left ventricular function intact, unchanged from pre-bypass 3. Right ventricular function intact, unchanged from pre-bypass 4. Other valvular function intact, unchanged 5. Aorta intact, no evidence of dissection I certify that I was present for this procedure in compliance with ___ regulations. Interpretation assigned to ___, MD, Interpreting physician © ___ ___. All rights reserved. . ___ 04:40AM BLOOD WBC-6.0 RBC-3.29* Hgb-10.6* Hct-31.1* MCV-95 MCH-32.2* MCHC-34.1 RDW-13.7 RDWSD-46.3 Plt ___ ___ 12:39AM BLOOD ___ PTT-24.3* ___ ___ 04:40AM BLOOD Glucose-87 UreaN-15 Creat-0.5 Na-136 K-3.7 Cl-98 HCO3-27 AnGap-___ipro was initiated for pre-op positive urinalysis. Culture returned negative and Cipro was discontinued. The patient was brought to the Operating Room on ___ where the patient underwent Mitral Valve repair with Dr. ___. Echo in OR revealed ___. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. She required Neo for hemodynamic support. She received packed red blood cells for blood loss anemia. Neo was subsequently weaned. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She developed post-op AFib and converted to SR with Amiodarone. She became hypotensive following two amio boluses. Hemodynamics recovered and she remained in SR. Anti-coagulation is not required due to brevity of AFib. She will remain on low dose PO Amio. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Estradiol 0.01 mg PO DAILY:PRN dryness 2. Aspirin 81 mg PO DAILY 3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 5. vit D3-vit K-berberine-hops 500-500-90-370 unit-mcg-mg-mg oral DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 3. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 5. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 9. Estradiol 0.01 mg PO DAILY:PRN dryness 10. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 11. vit D3-vit K-berberine-hops 500-500-90-370 unit-mcg-mg-mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - Mitral valve prolapse, Mitral valve insufficiency - Mild Sensorineural hearing loss - Osteoporosis - LAFB (left anterior fascicular block) Past Surgical History: - s/p total abdominal hysterectomy and right salpingo-oophorectomy - Saphenous vein laser ablation bilaterally - Fibroid removal - Right breast cyst removal - hyperplasia Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema 1+ Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **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: ___
[ "I340", "D62", "D689", "I4891", "I341", "H905", "R21", "M810" ]
Allergies: Percocet Chief Complaint: Mild DOE with Mildly diminished exercise tolerance Major Surgical or Invasive Procedure: [MASKED] Mitral valve repair with a resection of the middle scallop of the posterior leaflet P2, and a Gore- Tex neochordae to the middle scallop of the anterior leaflet A2, and a mitral valve commissuroplasty, mitral valve annuloplasty with a 34 [MASKED] annuloplasty band. History of Present Illness: This is a [MASKED] year old female with known mitral valve disease who has been followed closely with serial echocardiograms. Her most recent echocardiogram from [MASKED] worsening mitral regurgitation due to increased prolapse of the posterior leaflet. She notes that she is highly functional. She participates in spinning, yoga, dancing, and muscle conditioning. She continues to deny any shortness of breath or dyspnea or chest pain with these activities. She does report an increase in palpitations over the last year. She also notes dyspnea with climbing stairs or strong physical exertion. She denies syncope, chest pain, pre-syncope, orthopnea, PND and lower extremity edema. Since her last clinic visit she states that her symptoms have not changed. She is now admitted post-cath for MVR. Past Medical History: - Mitral valve prolapse, Mitral valve insufficiency - Mild Sensorineural hearing loss - Osteoporosis - LAFB (left anterior fascicular block) Past Surgical History: - s/p total abdominal hysterectomy and right salpingo-oophorectomy - Saphenous vein laser ablation bilaterally - Fibroid removal - Right breast cyst removal - hyperplasia Social History: [MASKED] Family History: Father with endocarditis. Brother with CAD. Physical Exam: Admission Exam: Vital Signs 97.7 PO, 131 / 82,98,18,96 Ra General: In NAD Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT, PERRLA [X] EOMI [X], Sclera anicteric, OP benign, No thyromegally Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, Occasional PVC, III/VI systolic murmur best heard at apex. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema [X] Varicosities: Superficial noted. h/o laser ablation. Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 [MASKED] Right:2 Left:2 Radial Right:2 Left:2 Carotid Bruit: None . Discharge Exam: Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [] Lungs: CTA [x] No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: no CCE[] Pulses doppler [] palpable [] 1+ edema Wounds: Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Pertinent Results: [MASKED] Intra-op TEE preliminary report Conclusions Pre-Bypass rhythm: sinus with prequent PVC infusions: phenylephrine 0.2mcg/kg/min 1. The left atrium is mildly dilated. 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. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 3. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. There is moderate/severe P1/P2 and A1/A2 leaflet mitral valve prolapse. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The [MASKED] distance is 2.1 and anterior to posterior leaflet length ratio >1.3. 5. The tricuspid valve leaflets are mildly thickened. Post Bypass rhythm: sinus infusions: phenylephrine 0.6mcg/kg/min 1. Mitral valve with minimal residual regurgitation. There is evidence of intermittent dynamic systolic anterior motion of the anterior mitral valve leaflet. Evidence of aortic valve leaflet fluttering and late systolic closure of aortic valve. Gradient in LVOT >60. Findings discussed at length with cardiac surgeon, decision made to hydrate and slow down heart rate. 2. Left ventricular function intact, unchanged from pre-bypass 3. Right ventricular function intact, unchanged from pre-bypass 4. Other valvular function intact, unchanged 5. Aorta intact, no evidence of dissection I certify that I was present for this procedure in compliance with [MASKED] regulations. Interpretation assigned to [MASKED], MD, Interpreting physician © [MASKED] [MASKED]. All rights reserved. . [MASKED] 04:40AM BLOOD WBC-6.0 RBC-3.29* Hgb-10.6* Hct-31.1* MCV-95 MCH-32.2* MCHC-34.1 RDW-13.7 RDWSD-46.3 Plt [MASKED] [MASKED] 12:39AM BLOOD [MASKED] PTT-24.3* [MASKED] [MASKED] 04:40AM BLOOD Glucose-87 UreaN-15 Creat-0.5 Na-136 K-3.7 Cl-98 HCO3-27 AnGap- ipro was initiated for pre-op positive urinalysis. Culture returned negative and Cipro was discontinued. The patient was brought to the Operating Room on [MASKED] where the patient underwent Mitral Valve repair with Dr. [MASKED]. Echo in OR revealed [MASKED]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. She required Neo for hemodynamic support. She received packed red blood cells for blood loss anemia. Neo was subsequently weaned. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She developed post-op AFib and converted to SR with Amiodarone. She became hypotensive following two amio boluses. Hemodynamics recovered and she remained in SR. Anti-coagulation is not required due to brevity of AFib. She will remain on low dose PO Amio. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Estradiol 0.01 mg PO DAILY:PRN dryness 2. Aspirin 81 mg PO DAILY 3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 5. vit D3-vit K-berberine-hops 500-500-90-370 unit-mcg-mg-mg oral DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 3. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*1 5. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 9. Estradiol 0.01 mg PO DAILY:PRN dryness 10. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 11. vit D3-vit K-berberine-hops 500-500-90-370 unit-mcg-mg-mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: - Mitral valve prolapse, Mitral valve insufficiency - Mild Sensorineural hearing loss - Osteoporosis - LAFB (left anterior fascicular block) Past Surgical History: - s/p total abdominal hysterectomy and right salpingo-oophorectomy - Saphenous vein laser ablation bilaterally - Fibroid removal - Right breast cyst removal - hyperplasia Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema 1+ Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **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]
[]
[ "D62", "I4891" ]
[ "I340: Nonrheumatic mitral (valve) insufficiency", "D62: Acute posthemorrhagic anemia", "D689: Coagulation defect, unspecified", "I4891: Unspecified atrial fibrillation", "I341: Nonrheumatic mitral (valve) prolapse", "H905: Unspecified sensorineural hearing loss", "R21: Rash and other nonspecific skin eruption", "M810: Age-related osteoporosis without current pathological fracture" ]
10,065,584
20,108,164
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Patient told to come to ED by neurologist whom found right internal carotid occlusion and right posterior circulation infarction. Major Surgical or Invasive Procedure: None History of Present Illness: ___ Is a ___ man with no significant past medical history who presents after discovery of a right PCA territory infarct on an MRI that was performed the day of presentation. The history is obtained from the patient. He reports that for the past 14 months, he has had "ocular migraines". He describes these as visual changes, mostly involving the right eye (although he did not do his cover-uncover test) where he would have intermittent loss of vision in the right eye, or part of his vision missing in his left visual field, including either the top medial portion of his vision, the lower medial portion of his vision, or the entire nasal visual field. He was evaluated by ophthalmology intermittently, who did not discover any abnormal findings with the eye, and gave him the diagnosis of ocular migraines. On ___, he developed A different sort of headache, which involved a dull holoacranial pressure-like sensation, which was very severe. This was associated with nausea and vomiting, as well as lightheadedness, photophobia. He initially presented to an outside hospital, and was again given the diagnosis of migraines. He underwent a CT at the outside hospital, which was reportedly normal. Given the new onset of migraines, he was referred to neurology as an outpatient. He saw an outpatient neurologist on ___, who reportedly did not find any abnormal findings on neurologic exam, and ordered an MRI to evaluate for structural causes of headache. For multiple reasons, this MRI was not done until ___, which was done with an MRA with and without contrast. This discovered a totally occluded right ICA as well as a cut off in the right proximal PCA, with a subacute appearing infarct in the right PCA territory. The patient was advised to immediately come to ___ for further workup. Regarding his risk factors, the patient reports that he has had multiple traumas, from old ___'s and football injuries. However the last ones that he had were about ___ years ago. None of these events were associated with the development of unilateral neurologic symptoms. Of note, he developed palpitations in ___, and reportedly underwent a workup including a Holter monitor and transthoracic echo, revealing PVCs but no evidence of atrial fibrillation or other tachyarrhythmias. He is not sure if he has an ASD or PFO. He does admit to snoring, and his wife at bedside attests to frequent episodes of apnea. He does not have any daytime somnolence. He has not had a sleep study. No current constitutional symptoms. Past Medical History: No past medical history. Social History: ___ Family History: Father died of unclear causes in his early ___. No history of early stroke or MI in the family. Maternal grandmother had some kind of cancer. No history of hypercoagulability in the family. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 97.5 HR: 70-103 BP: 147/94 RR: 15 SaO2: 99% on room air General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. Able to register 3 objects and recall ___ at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. There is left upper quadrantanopia. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [___] L 5 5 5 5 ___ 5 5 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [___] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: No deficits to light touch, pin, or proprioception bilaterally. No extinction to DSS. No graphesthesia bilaterally. - Coordination: No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait: Deferred DISCHARGE PHYSICAL EXAMINATION: Vitals: Temperature: 98.6 Blood pressure: 109/71 Heart rate: 69 Respiratory rate: 14 Oxygen saturation 96% on RA General physical examination: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Patient is alert and oriented to name, place, and location. Patient is able to provide his history of present illness and is able to follow commands during examination. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Left upper quadrantanopia. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 Sensory: No deficits to light touch, proprioception throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: A1C: 5.4% LDL: 118 TSH: 3.0 CT/CTA: 1. Complete occlusion of the right internal carotid artery just superior to the bifurcation with reconstitution at the paraclinoid segment corrseponding to findings on MRA (3:169, 3:175, 4:277). 2. Fetal subtype right PCA with highly attenuated and possibly occluded right P2 segment (3:294, 295). 3. Patent circle of ___, bilateral ACA, M1, and MCA arborization. MRI Brain from outside facility: Right posterior circulation infarction. TTE: No thrombus or PFO. Brief Hospital Course: Patient is a ___ year old male with no past medical history whom presented to ___ ED ___ after his neurologist notified him of abnormal image findings from studies done on ___. Patient found to have complete occlusion of the right internal carotid artery superior to the bifurcation and an acute/subacute stroke in right posterior circulation. Patient's neurologic examination remarkable for left upper quadrantanopia. Plan for DAPT for 3 months with clopidogrel and aspirin and then to resume aspirin thereafter. Patient has also been started on atorvastatin for high cholesterol. Patient had unremarkable TTE. Patient encouraged to stop smoking. Patient given numbers for follow up with PCP and stroke team. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =118 ) - () 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? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 2. Atorvastatin 80 mg PO QPM HLD RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 3. Clopidogrel 75 mg PO DAILY Duration: 3 Months Please take for only 3 months then discontinue RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Right posterior cerebral artery infarct Occlusion of right internal carotid artery Hypoplastic right posterior cerebral artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, During this admission, you presented at the recommendation of your neurologist because your imaging revealed complete occlusion of an artery on the right side of your head/neck that is important to bringing blood to your brain and because there was a recent stroke identified. For the occluded vessel, there is no surgical correction indicated, and your body has developed alternative vessels to bring blood to the portion of the brain normally supplied by the occluded vessel. The stroke (low blood flow to the brain) affected a region of the brain that is important in vision, and on examination, you have a small visual field cut (loss of vision). You might have difficulty with vision when looking up and to the left. Our goal now is to prevent you from having development of other occlusions in important brain blood vessels and to prevent another stroke. First, we have started you on aspirin 81 mg daily and clopidogrel 75mg daily. After 3 months, you can stop the clopidogrel. These medications, which helps to prevent blood clotting, has been shown to reduce risk of stroke recurrence. You were also found to have high cholesterol and have been started on a cholesterol lowering medication, atorvastatin 40 mg daily. The ultrasound (echocardiogram) of your heart did not demonstrate a hole or a clot in your heart. In addition to starting the above two medications, we highly recommend that you stop smoking cigarettes as this is a major risk factor for stroke. We also recommend a heart healthy diet and engaging in regular physical activity. Thank you for allowing us to care for you, ___ Stroke Team Followup Instructions: ___
[ "I63231", "Q283", "I672", "H53462", "F17210", "Z823", "E785" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Patient told to come to ED by neurologist whom found right internal carotid occlusion and right posterior circulation infarction. Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] Is a [MASKED] man with no significant past medical history who presents after discovery of a right PCA territory infarct on an MRI that was performed the day of presentation. The history is obtained from the patient. He reports that for the past 14 months, he has had "ocular migraines". He describes these as visual changes, mostly involving the right eye (although he did not do his cover-uncover test) where he would have intermittent loss of vision in the right eye, or part of his vision missing in his left visual field, including either the top medial portion of his vision, the lower medial portion of his vision, or the entire nasal visual field. He was evaluated by ophthalmology intermittently, who did not discover any abnormal findings with the eye, and gave him the diagnosis of ocular migraines. On [MASKED], he developed A different sort of headache, which involved a dull holoacranial pressure-like sensation, which was very severe. This was associated with nausea and vomiting, as well as lightheadedness, photophobia. He initially presented to an outside hospital, and was again given the diagnosis of migraines. He underwent a CT at the outside hospital, which was reportedly normal. Given the new onset of migraines, he was referred to neurology as an outpatient. He saw an outpatient neurologist on [MASKED], who reportedly did not find any abnormal findings on neurologic exam, and ordered an MRI to evaluate for structural causes of headache. For multiple reasons, this MRI was not done until [MASKED], which was done with an MRA with and without contrast. This discovered a totally occluded right ICA as well as a cut off in the right proximal PCA, with a subacute appearing infarct in the right PCA territory. The patient was advised to immediately come to [MASKED] for further workup. Regarding his risk factors, the patient reports that he has had multiple traumas, from old [MASKED]'s and football injuries. However the last ones that he had were about [MASKED] years ago. None of these events were associated with the development of unilateral neurologic symptoms. Of note, he developed palpitations in [MASKED], and reportedly underwent a workup including a Holter monitor and transthoracic echo, revealing PVCs but no evidence of atrial fibrillation or other tachyarrhythmias. He is not sure if he has an ASD or PFO. He does admit to snoring, and his wife at bedside attests to frequent episodes of apnea. He does not have any daytime somnolence. He has not had a sleep study. No current constitutional symptoms. Past Medical History: No past medical history. Social History: [MASKED] Family History: Father died of unclear causes in his early [MASKED]. No history of early stroke or MI in the family. Maternal grandmother had some kind of cancer. No history of hypercoagulability in the family. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 97.5 HR: 70-103 BP: 147/94 RR: 15 SaO2: 99% on room air General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple [MASKED]: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. Able to register 3 objects and recall [MASKED] at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. There is left upper quadrantanopia. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [[MASKED]] L 5 5 5 5 [MASKED] 5 5 5 5 5 R 5 5 5 5 [MASKED] 5 5 5 5 5 - Reflexes: [Bic] [Tri] [[MASKED]] [Quad] [[MASKED]] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: No deficits to light touch, pin, or proprioception bilaterally. No extinction to DSS. No graphesthesia bilaterally. - Coordination: No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait: Deferred DISCHARGE PHYSICAL EXAMINATION: Vitals: Temperature: 98.6 Blood pressure: 109/71 Heart rate: 69 Respiratory rate: 14 Oxygen saturation 96% on RA General physical examination: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Patient is alert and oriented to name, place, and location. Patient is able to provide his history of present illness and is able to follow commands during examination. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Left upper quadrantanopia. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] 5 [MASKED] 5 5 5 5 5 R 5 [MASKED] 5 [MASKED] 5 5 5 5 5 Sensory: No deficits to light touch, proprioception throughout. No extinction to DSS. Reflexes: Bi Tri [MASKED] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: A1C: 5.4% LDL: 118 TSH: 3.0 CT/CTA: 1. Complete occlusion of the right internal carotid artery just superior to the bifurcation with reconstitution at the paraclinoid segment corrseponding to findings on MRA (3:169, 3:175, 4:277). 2. Fetal subtype right PCA with highly attenuated and possibly occluded right P2 segment (3:294, 295). 3. Patent circle of [MASKED], bilateral ACA, M1, and MCA arborization. MRI Brain from outside facility: Right posterior circulation infarction. TTE: No thrombus or PFO. Brief Hospital Course: Patient is a [MASKED] year old male with no past medical history whom presented to [MASKED] ED [MASKED] after his neurologist notified him of abnormal image findings from studies done on [MASKED]. Patient found to have complete occlusion of the right internal carotid artery superior to the bifurcation and an acute/subacute stroke in right posterior circulation. Patient's neurologic examination remarkable for left upper quadrantanopia. Plan for DAPT for 3 months with clopidogrel and aspirin and then to resume aspirin thereafter. Patient has also been started on atorvastatin for high cholesterol. Patient had unremarkable TTE. Patient encouraged to stop smoking. Patient given numbers for follow up with PCP and stroke team. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =118 ) - () 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? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 2. Atorvastatin 80 mg PO QPM HLD RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*5 3. Clopidogrel 75 mg PO DAILY Duration: 3 Months Please take for only 3 months then discontinue RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Right posterior cerebral artery infarct Occlusion of right internal carotid artery Hypoplastic right posterior cerebral artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], During this admission, you presented at the recommendation of your neurologist because your imaging revealed complete occlusion of an artery on the right side of your head/neck that is important to bringing blood to your brain and because there was a recent stroke identified. For the occluded vessel, there is no surgical correction indicated, and your body has developed alternative vessels to bring blood to the portion of the brain normally supplied by the occluded vessel. The stroke (low blood flow to the brain) affected a region of the brain that is important in vision, and on examination, you have a small visual field cut (loss of vision). You might have difficulty with vision when looking up and to the left. Our goal now is to prevent you from having development of other occlusions in important brain blood vessels and to prevent another stroke. First, we have started you on aspirin 81 mg daily and clopidogrel 75mg daily. After 3 months, you can stop the clopidogrel. These medications, which helps to prevent blood clotting, has been shown to reduce risk of stroke recurrence. You were also found to have high cholesterol and have been started on a cholesterol lowering medication, atorvastatin 40 mg daily. The ultrasound (echocardiogram) of your heart did not demonstrate a hole or a clot in your heart. In addition to starting the above two medications, we highly recommend that you stop smoking cigarettes as this is a major risk factor for stroke. We also recommend a heart healthy diet and engaging in regular physical activity. Thank you for allowing us to care for you, [MASKED] Stroke Team Followup Instructions: [MASKED]
[]
[ "F17210", "E785" ]
[ "I63231: Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries", "Q283: Other malformations of cerebral vessels", "I672: Cerebral atherosclerosis", "H53462: Homonymous bilateral field defects, left side", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z823: Family history of stroke", "E785: Hyperlipidemia, unspecified" ]
10,065,584
29,885,402
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: transient R monocular visual obscurations Major Surgical or Invasive Procedure: n/a History of Present Illness: transient right monocular vision loss/obscuration for the past ___ months, initially diagnosed as ocular migraines but subsequent felt to represent amaurosis fugax from carotid atherosclerotic embolism, in the setting of recently diagnosed right internal carotid artery occlusion, who now presents for recurrence of similar episodes after initiating on dual antiplatelet therapy. Patient's history is summarized as above; he had numerous (>50) episodes in the past year, typically characterized by loss of vision in the right eye for a few minutes. Some of them were associated with positive sparkling phenomenon in that eye, followed by headache, and he was initially diagnosed with ocular migraine. He eventually was evaluated by a neurologist who ordered MRI/MRA, which on ___ demonstrated a subacute right temporal/occipital lobe infarct, as well as complete right ICU occlusion and a fetal right PCA with possible occlusion. He was admitted directly to Stroke service and underwent further workup. He was started on dual antiplatelet therapy with aspirin 81mg and plavix 75mg, as well as atorvastatin 40mg, and was discharged home. Exam was notable only for an upper left quadrantanopsia. Since discharge, he has been well and had no recurrence of symptoms, until this morning. Between ___, while at work walking to his desk, he had 3 separate episodes of "graying" of the vision of his right eye, involving the entire field. He was still able to discern most images but as if there was a "cloud" covering his eye. There was no pain involved. Each episode was <1 minute, and all started and resolved acutely and spontaneously, without any triggers. Of note, he has also experienced occasional right arm numbness described as a "cool" sensation over his forearm, as though recovering from anesthesia. He saw Dr. ___ last week for follow up of his admission, who had planned on repeating head MRI to evaluate these symptoms. He called his PCP and was told to come to clinic; subsequently he was transferred to ___ for evaluation. Head CT was obtained which was read with concern for infarct, however compared to head CT obtained during last admission, appears stable. He was subsequently transferred to ___ ___. At current time of interview pt states he is completely back to baseline and has no deficits at this time. ROS is only positive for some mild "mental fogginess" which he attributes to recently starting on fluoxetine by his PCP 3 weeks ago. Of note, his SBP was in the 100s at the office, when typically he runs in 120-130s. Past Medical History: CVA Right carotid artery occlusion Multiple rotator cuff surgeries Osteomyelitis of the right foot after stepping on a rusty nail Social History: ___ Family History: Father died of unclear causes in his early ___. No history of early stroke or MI in the family. Maternal grandmother had some kind of cancer. No history of hypercoagulability in the family. Physical Exam: ADMISSION PHYSICAL EXAM Physical Exam: Vitals: 97.9 83 144/84 18 99% RA General: awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple, no nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: RRR, nl Abdomen: soft, NT/ND Extremities: warm, well perfused Skin: no rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 6 to 4mm and brisk, no rAPD. ___: ___ ___. EOMI without nystagmus. Normal saccades. Homonymous left upper quadrantanopsia. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages ___. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ******************* DISCHARGE PHYSICAL EXAM As above Pertinent Results: ___ 02:00PM BLOOD WBC-8.4 RBC-4.29* Hgb-13.9 Hct-41.3 MCV-96 MCH-32.4* MCHC-33.7 RDW-13.8 RDWSD-49.1* Plt ___ ___ 02:00PM BLOOD Neuts-62.3 ___ Monos-7.2 Eos-0.7* Baso-0.7 Im ___ AbsNeut-5.21 AbsLymp-2.40 AbsMono-0.60 AbsEos-0.06 AbsBaso-0.06 ___ 02:00PM BLOOD ___ PTT-34.0 ___ ___ 02:00PM BLOOD Glucose-137* UreaN-9 Creat-0.8 Na-138 K-3.9 Cl-99 HCO3-27 AnGap-12 ___ 02:00PM BLOOD cTropnT-<0.01 IMAGING STUDIES MRI head w/o contrast ___. Evolution of right temporal occipital infarct described on examination of ___. There is a small linear region of minimally increased DWI intermediate ADC values in the right temporal lobe within the known infarct, felt to most likely represent differential aging of infarct. 2. Persistent thrombosis of the visualized distal right ICA. 3. The previously noted occlusion of the right PCA is suboptimally assessed on this nondedicated study. 4. Additional findings as described above. Non-Contrast CT of Head (OSH, my read): Hypodensity in the right medial temporal and occipital lobes, stable since last exam ___. No additional acute abnormalities. Brief Hospital Course: ___ year old man with recent diagnosis of right carotid occlusion and Right posterior cerebral artery infarct, who presents with episodes of visual loss. The concern is that his visual disturbances could be due to hypoperfusion of central retinal artery versus emboli from the occluded right carotid artery. His examination is at baseline now, demonstrating only superior left quadrantanopsia, with no evidence of acute occlusion or hemorrhage on fundoscopic exam of the right eye. His symptoms are most likely attributable to hypoperfusion of the right central retinal artery, given clinical description, known complete occlusion and slightly lower BP than usual on presentation. The other, less likely possibility is emboli from the chronically occluded distal right ICA. Given the reconstitution of the right ICA flow at the level of the ophthalmic artery and cavernous ICA, there is likely bidirectional flow along the ophthalmic artery. If his blood pressure drops, he may be at risk for right eye retinal artery ischemia. MRI brain does not show a new infarct but does show the chronic right occipital infarct. Moving forward, optimal management would be maintaining adequate perfusion via increasing blood pressure, and optimizing medical therapy with full dose statin and continuing dual antiplatelet therapy. TRANSITIONAL ISSUES: -Start midodrine 5mg daily. In the long term, this may be able to weaned off long term assuming enough collaterals develop. -Check blood pressures at least daily, goal systolic 110-140, goal diastolic ___ -Increase atorvastatin from 40mg to 80mg -Check labs as outpatient (antiphospholipid, CRP) which can assess for risk factor for stroke Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Midodrine 5 mg PO DAILY RX *midodrine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Aspirin 81 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Hypoperfusion to the right central retinal artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after having several episodes of visual loss. Fortunately your symptoms improved. After further evaluation, we believe your symptoms are most likely due to diminished blood flow to your retina, a part of your eye involved in vision. To treat your symptoms, we will start Midodrine, a medication to increase blood pressure and blood flow to this area. It will be important to keep your blood pressure at least 110 to 140 systolic over 70 to 90 diastolic. It will be important for you to check your blood pressures at home. We will also increase your atorvastatin to treat your high cholesterol and reduce risk of further events. We will also check some labs that may increase your risk of developing further events. 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, high cholesterol. We are changing your medications as follows: -Increased atorvastatin to 80mg daily -Started midodrine 5mg daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
[ "H3401", "I6329", "I6521", "H53462", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: transient R monocular visual obscurations Major Surgical or Invasive Procedure: n/a History of Present Illness: transient right monocular vision loss/obscuration for the past [MASKED] months, initially diagnosed as ocular migraines but subsequent felt to represent amaurosis fugax from carotid atherosclerotic embolism, in the setting of recently diagnosed right internal carotid artery occlusion, who now presents for recurrence of similar episodes after initiating on dual antiplatelet therapy. Patient's history is summarized as above; he had numerous (>50) episodes in the past year, typically characterized by loss of vision in the right eye for a few minutes. Some of them were associated with positive sparkling phenomenon in that eye, followed by headache, and he was initially diagnosed with ocular migraine. He eventually was evaluated by a neurologist who ordered MRI/MRA, which on [MASKED] demonstrated a subacute right temporal/occipital lobe infarct, as well as complete right ICU occlusion and a fetal right PCA with possible occlusion. He was admitted directly to Stroke service and underwent further workup. He was started on dual antiplatelet therapy with aspirin 81mg and plavix 75mg, as well as atorvastatin 40mg, and was discharged home. Exam was notable only for an upper left quadrantanopsia. Since discharge, he has been well and had no recurrence of symptoms, until this morning. Between [MASKED], while at work walking to his desk, he had 3 separate episodes of "graying" of the vision of his right eye, involving the entire field. He was still able to discern most images but as if there was a "cloud" covering his eye. There was no pain involved. Each episode was <1 minute, and all started and resolved acutely and spontaneously, without any triggers. Of note, he has also experienced occasional right arm numbness described as a "cool" sensation over his forearm, as though recovering from anesthesia. He saw Dr. [MASKED] last week for follow up of his admission, who had planned on repeating head MRI to evaluate these symptoms. He called his PCP and was told to come to clinic; subsequently he was transferred to [MASKED] for evaluation. Head CT was obtained which was read with concern for infarct, however compared to head CT obtained during last admission, appears stable. He was subsequently transferred to [MASKED] [MASKED]. At current time of interview pt states he is completely back to baseline and has no deficits at this time. ROS is only positive for some mild "mental fogginess" which he attributes to recently starting on fluoxetine by his PCP 3 weeks ago. Of note, his SBP was in the 100s at the office, when typically he runs in 120-130s. Past Medical History: CVA Right carotid artery occlusion Multiple rotator cuff surgeries Osteomyelitis of the right foot after stepping on a rusty nail Social History: [MASKED] Family History: Father died of unclear causes in his early [MASKED]. No history of early stroke or MI in the family. Maternal grandmother had some kind of cancer. No history of hypercoagulability in the family. Physical Exam: ADMISSION PHYSICAL EXAM Physical Exam: Vitals: 97.9 83 144/84 18 99% RA General: awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple, no nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: RRR, nl Abdomen: soft, NT/ND Extremities: warm, well perfused Skin: no rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 6 to 4mm and brisk, no rAPD. [MASKED]: [MASKED] [MASKED]. EOMI without nystagmus. Normal saccades. Homonymous left upper quadrantanopsia. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages [MASKED]. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ******************* DISCHARGE PHYSICAL EXAM As above Pertinent Results: [MASKED] 02:00PM BLOOD WBC-8.4 RBC-4.29* Hgb-13.9 Hct-41.3 MCV-96 MCH-32.4* MCHC-33.7 RDW-13.8 RDWSD-49.1* Plt [MASKED] [MASKED] 02:00PM BLOOD Neuts-62.3 [MASKED] Monos-7.2 Eos-0.7* Baso-0.7 Im [MASKED] AbsNeut-5.21 AbsLymp-2.40 AbsMono-0.60 AbsEos-0.06 AbsBaso-0.06 [MASKED] 02:00PM BLOOD [MASKED] PTT-34.0 [MASKED] [MASKED] 02:00PM BLOOD Glucose-137* UreaN-9 Creat-0.8 Na-138 K-3.9 Cl-99 HCO3-27 AnGap-12 [MASKED] 02:00PM BLOOD cTropnT-<0.01 IMAGING STUDIES MRI head w/o contrast [MASKED]. Evolution of right temporal occipital infarct described on examination of [MASKED]. There is a small linear region of minimally increased DWI intermediate ADC values in the right temporal lobe within the known infarct, felt to most likely represent differential aging of infarct. 2. Persistent thrombosis of the visualized distal right ICA. 3. The previously noted occlusion of the right PCA is suboptimally assessed on this nondedicated study. 4. Additional findings as described above. Non-Contrast CT of Head (OSH, my read): Hypodensity in the right medial temporal and occipital lobes, stable since last exam [MASKED]. No additional acute abnormalities. Brief Hospital Course: [MASKED] year old man with recent diagnosis of right carotid occlusion and Right posterior cerebral artery infarct, who presents with episodes of visual loss. The concern is that his visual disturbances could be due to hypoperfusion of central retinal artery versus emboli from the occluded right carotid artery. His examination is at baseline now, demonstrating only superior left quadrantanopsia, with no evidence of acute occlusion or hemorrhage on fundoscopic exam of the right eye. His symptoms are most likely attributable to hypoperfusion of the right central retinal artery, given clinical description, known complete occlusion and slightly lower BP than usual on presentation. The other, less likely possibility is emboli from the chronically occluded distal right ICA. Given the reconstitution of the right ICA flow at the level of the ophthalmic artery and cavernous ICA, there is likely bidirectional flow along the ophthalmic artery. If his blood pressure drops, he may be at risk for right eye retinal artery ischemia. MRI brain does not show a new infarct but does show the chronic right occipital infarct. Moving forward, optimal management would be maintaining adequate perfusion via increasing blood pressure, and optimizing medical therapy with full dose statin and continuing dual antiplatelet therapy. TRANSITIONAL ISSUES: -Start midodrine 5mg daily. In the long term, this may be able to weaned off long term assuming enough collaterals develop. -Check blood pressures at least daily, goal systolic 110-140, goal diastolic [MASKED] -Increase atorvastatin from 40mg to 80mg -Check labs as outpatient (antiphospholipid, CRP) which can assess for risk factor for stroke Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Midodrine 5 mg PO DAILY RX *midodrine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Aspirin 81 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Hypoperfusion to the right central retinal artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital after having several episodes of visual loss. Fortunately your symptoms improved. After further evaluation, we believe your symptoms are most likely due to diminished blood flow to your retina, a part of your eye involved in vision. To treat your symptoms, we will start Midodrine, a medication to increase blood pressure and blood flow to this area. It will be important to keep your blood pressure at least 110 to 140 systolic over 70 to 90 diastolic. It will be important for you to check your blood pressures at home. We will also increase your atorvastatin to treat your high cholesterol and reduce risk of further events. We will also check some labs that may increase your risk of developing further events. 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, high cholesterol. We are changing your medications as follows: -Increased atorvastatin to 80mg daily -Started midodrine 5mg daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "Z7902" ]
[ "H3401: Transient retinal artery occlusion, right eye", "I6329: Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries", "I6521: Occlusion and stenosis of right carotid artery", "H53462: Homonymous bilateral field defects, left side", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,065,615
28,895,318
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Zemplar / Ampicillin Attending: ___ Chief Complaint: right gluteal abscess Major Surgical or Invasive Procedure: Incision and drainage History of Present Illness: ___ male, history of ESRD s/p deceased donor renal transplant (___) on immunosuppression, atrial fibrillation on Eliquis, hypertension who presented with 1 week of pain and redness of the right buttock and found to have an abscess. Patient reported that he noticed a region of erythema 1 week ago, which had enlarged and become progressively more painful. He denied fevers, chills or other systemic symptoms. Past Medical History: 1.Hypertension 2.status post bioprosthetic aortic valve replacement 3.history of endocarditis 4.End stage renal disease secondary to hypertension, nephrosclerosis + Acute TMA Social History: ___ Family History: Father and mother died at age ___. Brothers with hypertension. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.1 PO 150 / 81 75 16 98 Ra GENERAL: NAD HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: irregularly irregular rate, regular rhythm, S1/S2, systolic murmur heard loudest at apex with S4 LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, large erythematous abscess on right buttock near gluteal fold with surrounding cellulitis s/p I&D draining purulent material and blood, dressing soaked through and replaced, images ___ ___ DISCHARGE PHYSICAL EXAM ======================= VS: 24 HR Data (last updated ___ @ 738) Temp: 97.7 (Tm 98.5), BP: 127/75 (108-153/65-82), HR: 59 (56-71), RR: 18 (___), O2 sat: 97% (96-98), O2 delivery: Ra GENERAL: male ___ NAD HEART: irregularly, irregular rate, regular rhythm, no m/r/g LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender ___ all quadrants, no rebound/guarding EXTREMITIES: no edema NEURO: alert, moving all 4 extremities with purpose Right buttocks: reduced ___ size, 2x3.5cm ecchymotic and erythematous area of induration circumferential about open, previously lanced wound; currently packed and covered with 4x4 on right buttocks. Serosanguinous drainage. LABORATORY DATA: Reviewed ___ ___. Pertinent Results: ADMISSION LABS ============== ___ 03:52PM WBC-9.4 RBC-4.98 HGB-15.0 HCT-46.4 MCV-93 MCH-30.1 MCHC-32.3 RDW-12.1 RDWSD-41.1 ___ 03:52PM NEUTS-78.3* LYMPHS-11.9* MONOS-8.4 EOS-0.6* BASOS-0.4 IM ___ AbsNeut-7.32* AbsLymp-1.11* AbsMono-0.79 AbsEos-0.06 AbsBaso-0.04 ___ 03:52PM ALT(SGPT)-11 AST(SGOT)-10 ALK PHOS-63 TOT BILI-0.6 ___ 03:52PM GLUCOSE-151* UREA N-14 CREAT-0.9 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 ___ 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100* GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG DISCHARGE LABS ============== ___ 05:40AM BLOOD WBC-6.3 RBC-5.17 Hgb-15.5 Hct-48.0 MCV-93 MCH-30.0 MCHC-32.3 RDW-12.1 RDWSD-41.6 Plt ___ ___ 05:40AM BLOOD Glucose-130* UreaN-14 Creat-0.9 Na-143 K-4.5 Cl-105 HCO3-23 AnGap-15 ___ 05:40AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.6 ___ 05:40AM BLOOD Vanco-13.9 ___ 05:40AM BLOOD tacroFK-4.8* MICRO ===== Blood cultures - no growth to date Urine culture - <10k CFUs ___ 8:09 am SWAB Source: buttock. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. NO IMAGING. Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Patient discharged at baseline renal function without changes to his tacrolimus dosing. [] He was discharged to complete a 14 day total antibiotic course with augmentin (end date ___. Patient with noted history of rash with ampicillin - please monitor for allergic symptoms (he did not demonstrate any symptoms after one dose prior to discharge). Discharge Tacrolimus level: 4.8 # CODE: Full Code presumed # CONTACT: son, ___, ___ BRIEF HOSPITAL COURSE ===================== ___ male, history of ESRD secondary to hypertensive nephropathy/IgA nephropathy s/p deceased donor renal transplant ___ ___ on tacro/MMF/prednisone, atrial fibrillation on apixaban presenting with one week of pain and redness of the right buttock found to have an abscess. He underwent incision and drainage of the wound and was started on IV vancomycin. ID consulted. He was continued on his home immunosuppressive regimen. Wound cultures grew coagulant negative staph pan-sensitive. He was started on Augmentin to complete a 14 day course of antibiotics. He also demonstrated proficiency at dressing changes and wound hygiene. He was discharged home without services. ACTIVE ISSUES ============= # Right gluteal cellulitis/abscess Patient presented with 1 week of pain, erythema of buttock and found to have draining abscess. Infectious disease consulted. Continued on IV vancomycin (day ___ with transition to PO augmentin to complete 14 day antibiotic course (end date ___. #DDRT Deceased donor kidney transplantation from a ___ high risk donor on ___. Continued on mycophenolate mofetil 500mg bid, prednisone 5mg daily, and tacrolimus 0.5mg bid (goal trough of approximately ___ per prior notes). CHRONIC ISSUES ============== #Atrial Fibrillation Continued coreg and apixaban. #HTN Continued enalapril and coreg. #HLD Continued simvastatin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 3. Enalapril Maleate 10 mg PO DAILY 4. CARVedilol 3.125 mg PO BID 5. Apixaban 5 mg PO BID 6. Famotidine 20 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Mycophenolate Mofetil 500 mg PO BID 9. Tacrolimus 0.5 mg PO Q12H 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 11. Vitamin D 4000 UNIT PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 3. Apixaban 5 mg PO BID 4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 5. CARVedilol 3.125 mg PO BID 6. Enalapril Maleate 10 mg PO DAILY 7. Famotidine 20 mg PO DAILY 8. Mycophenolate Mofetil 500 mg PO BID 9. PredniSONE 5 mg PO DAILY 10. Simvastatin 20 mg PO QPM 11. Tacrolimus 0.5 mg PO Q12H 12. Vitamin D 4000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS ================= Right gluteal abscess SECONDARY DIAGNOSES =================== Renal transplant ___ Atrial fibrillation Hypertension Hyperlipidemia History of bioprosthetic aortic valve replacement ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear, Mr. ___, You were admitted to the hospital because you had an infection of the skin ___ your buttocks. WHAT HAPPENED WHILE YOU WERE ___ THE HOSPITAL? - You had the wound drained and were given antibiotics. - 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 - 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 ___ your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
[ "L0231", "L03317", "B9561", "I130", "N2581", "Z940", "N189", "I509", "I4891", "I2510", "E785", "Z7902", "Z952", "Z87891" ]
Allergies: Zemplar / Ampicillin Chief Complaint: right gluteal abscess Major Surgical or Invasive Procedure: Incision and drainage History of Present Illness: [MASKED] male, history of ESRD s/p deceased donor renal transplant ([MASKED]) on immunosuppression, atrial fibrillation on Eliquis, hypertension who presented with 1 week of pain and redness of the right buttock and found to have an abscess. Patient reported that he noticed a region of erythema 1 week ago, which had enlarged and become progressively more painful. He denied fevers, chills or other systemic symptoms. Past Medical History: 1.Hypertension 2.status post bioprosthetic aortic valve replacement 3.history of endocarditis 4.End stage renal disease secondary to hypertension, nephrosclerosis + Acute TMA Social History: [MASKED] Family History: Father and mother died at age [MASKED]. Brothers with hypertension. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.1 PO 150 / 81 75 16 98 Ra GENERAL: NAD HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: irregularly irregular rate, regular rhythm, S1/S2, systolic murmur heard loudest at apex with S4 LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender [MASKED] all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, large erythematous abscess on right buttock near gluteal fold with surrounding cellulitis s/p I&D draining purulent material and blood, dressing soaked through and replaced, images [MASKED] [MASKED] DISCHARGE PHYSICAL EXAM ======================= VS: 24 HR Data (last updated [MASKED] @ 738) Temp: 97.7 (Tm 98.5), BP: 127/75 (108-153/65-82), HR: 59 (56-71), RR: 18 ([MASKED]), O2 sat: 97% (96-98), O2 delivery: Ra GENERAL: male [MASKED] NAD HEART: irregularly, irregular rate, regular rhythm, no m/r/g LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender [MASKED] all quadrants, no rebound/guarding EXTREMITIES: no edema NEURO: alert, moving all 4 extremities with purpose Right buttocks: reduced [MASKED] size, 2x3.5cm ecchymotic and erythematous area of induration circumferential about open, previously lanced wound; currently packed and covered with 4x4 on right buttocks. Serosanguinous drainage. LABORATORY DATA: Reviewed [MASKED] [MASKED]. Pertinent Results: ADMISSION LABS ============== [MASKED] 03:52PM WBC-9.4 RBC-4.98 HGB-15.0 HCT-46.4 MCV-93 MCH-30.1 MCHC-32.3 RDW-12.1 RDWSD-41.1 [MASKED] 03:52PM NEUTS-78.3* LYMPHS-11.9* MONOS-8.4 EOS-0.6* BASOS-0.4 IM [MASKED] AbsNeut-7.32* AbsLymp-1.11* AbsMono-0.79 AbsEos-0.06 AbsBaso-0.04 [MASKED] 03:52PM ALT(SGPT)-11 AST(SGOT)-10 ALK PHOS-63 TOT BILI-0.6 [MASKED] 03:52PM GLUCOSE-151* UREA N-14 CREAT-0.9 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 [MASKED] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100* GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG DISCHARGE LABS ============== [MASKED] 05:40AM BLOOD WBC-6.3 RBC-5.17 Hgb-15.5 Hct-48.0 MCV-93 MCH-30.0 MCHC-32.3 RDW-12.1 RDWSD-41.6 Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-130* UreaN-14 Creat-0.9 Na-143 K-4.5 Cl-105 HCO3-23 AnGap-15 [MASKED] 05:40AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.6 [MASKED] 05:40AM BLOOD Vanco-13.9 [MASKED] 05:40AM BLOOD tacroFK-4.8* MICRO ===== Blood cultures - no growth to date Urine culture - <10k CFUs [MASKED] 8:09 am SWAB Source: buttock. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CLUSTERS. WOUND CULTURE (Final [MASKED]: STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. NO IMAGING. Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Patient discharged at baseline renal function without changes to his tacrolimus dosing. [] He was discharged to complete a 14 day total antibiotic course with augmentin (end date [MASKED]. Patient with noted history of rash with ampicillin - please monitor for allergic symptoms (he did not demonstrate any symptoms after one dose prior to discharge). Discharge Tacrolimus level: 4.8 # CODE: Full Code presumed # CONTACT: son, [MASKED], [MASKED] BRIEF HOSPITAL COURSE ===================== [MASKED] male, history of ESRD secondary to hypertensive nephropathy/IgA nephropathy s/p deceased donor renal transplant [MASKED] [MASKED] on tacro/MMF/prednisone, atrial fibrillation on apixaban presenting with one week of pain and redness of the right buttock found to have an abscess. He underwent incision and drainage of the wound and was started on IV vancomycin. ID consulted. He was continued on his home immunosuppressive regimen. Wound cultures grew coagulant negative staph pan-sensitive. He was started on Augmentin to complete a 14 day course of antibiotics. He also demonstrated proficiency at dressing changes and wound hygiene. He was discharged home without services. ACTIVE ISSUES ============= # Right gluteal cellulitis/abscess Patient presented with 1 week of pain, erythema of buttock and found to have draining abscess. Infectious disease consulted. Continued on IV vancomycin (day [MASKED] with transition to PO augmentin to complete 14 day antibiotic course (end date [MASKED]. #DDRT Deceased donor kidney transplantation from a [MASKED] high risk donor on [MASKED]. Continued on mycophenolate mofetil 500mg bid, prednisone 5mg daily, and tacrolimus 0.5mg bid (goal trough of approximately [MASKED] per prior notes). CHRONIC ISSUES ============== #Atrial Fibrillation Continued coreg and apixaban. #HTN Continued enalapril and coreg. #HLD Continued simvastatin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 3. Enalapril Maleate 10 mg PO DAILY 4. CARVedilol 3.125 mg PO BID 5. Apixaban 5 mg PO BID 6. Famotidine 20 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Mycophenolate Mofetil 500 mg PO BID 9. Tacrolimus 0.5 mg PO Q12H 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 11. Vitamin D 4000 UNIT PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 3. Apixaban 5 mg PO BID 4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 5. CARVedilol 3.125 mg PO BID 6. Enalapril Maleate 10 mg PO DAILY 7. Famotidine 20 mg PO DAILY 8. Mycophenolate Mofetil 500 mg PO BID 9. PredniSONE 5 mg PO DAILY 10. Simvastatin 20 mg PO QPM 11. Tacrolimus 0.5 mg PO Q12H 12. Vitamin D 4000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: PRIMARY DIAGNOSIS ================= Right gluteal abscess SECONDARY DIAGNOSES =================== Renal transplant [MASKED] Atrial fibrillation Hypertension Hyperlipidemia History of bioprosthetic aortic valve replacement [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear, Mr. [MASKED], You were admitted to the hospital because you had an infection of the skin [MASKED] your buttocks. WHAT HAPPENED WHILE YOU WERE [MASKED] THE HOSPITAL? - You had the wound drained and were given antibiotics. - 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 - 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 [MASKED] your care. We wish you the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I130", "N189", "I4891", "I2510", "E785", "Z7902", "Z87891" ]
[ "L0231: Cutaneous abscess of buttock", "L03317: Cellulitis of buttock", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N2581: Secondary hyperparathyroidism of renal origin", "Z940: Kidney transplant status", "N189: Chronic kidney disease, unspecified", "I509: Heart failure, unspecified", "I4891: Unspecified atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z952: Presence of prosthetic heart valve", "Z87891: Personal history of nicotine dependence" ]
10,065,997
25,252,424
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PODIATRY Allergies: cephalexin / Bactrim Attending: ___. Chief Complaint: Right ___ toe infection Major Surgical or Invasive Procedure: ___: 1. Right Foot ___ toe debridement 2. Right ___ PIPJ arthroplasty History of Present Illness: Ms. ___ is a ___ with PMHx of DM c/b neuropathy, CHF, HTN presenting to the ED with c/o infection to the R ___ toe. She has been on 2 courses of 10 days of clindamycin without improvement. Pt endorses some improvement while finishing clindamycin a few days ago but now with dark eschar, persistent redness/pain. She has some numbness at the bottom of her feet from chronic neuropathy but able to walk even with painful second toe. She was instructed by her PCP two weeks ago to see podiatry about this issue but did not because of insurance issues. She reports mild fevers / chills at home the last few days. No chest pain/SOB. Total body joint pain which is chronic for many years. Past Medical History: PAST MEDICAL HISTORY: DM (c/b peripheral neuropathy) Hyperlipidemia Obesity CAD (cardiac catheter in ___: Reports not available, gets CP rarely. Has seen dr ___ in the past, cannot see Dr ___ due to insurance issues) CHF HTN Anxiety/depression PAST SURGICAL HISTORY: hysterectomy Social History: ___ Family History: Mother had diabetes and neuropathy. No family history of cancers or coronary disease. Her son just passed, they are doing an autopsy, unsure of cause of death. Her niece diagnosed with stage 4 melanoma, (it was her father who just died), not handling it well. Physical Exam: On Admission: VITALS: 97.3 71 137/68 16 99% RA GEN: NAD, AOx3 RESP: CTA ABD: obese, soft, ___ FOCUSED: ___ pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R ___ toe. Mild peripheral edema noted. R 2md toe with ulceration to the dorsal aspect of the PIPJ with dry eschar covering, underlying fibrotic tissue with exposed bone. No purulence or fluctuance noted. R ___ toe with erythema and warmth. hammertoe deformity to the ___ toe b/l. mild pain with palpation of the ulcerated area. NEURO: light touch sensation diminished to the ___ b/l. On Discharge: AVSS GEN: NAD, AOx3 CHEST: RRR RESP: CTA, no resp distress ABD: obese, soft, ___, non-distended, no rebounding or guarding ___ FOCUSED: ___ pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R ___ toe. Right ___ digit sutures intact with no signs of dehiscence. Erythema improved. No drainage. No malodor. Mild peripheral edema noted. No TTP to the ___ toe. No signs of any other open lesions. Able to wiggle all toes x 10 NEURO: light touch sensation diminished to the ___ b/l. Pertinent Results: On Admission: ___ 04:45PM BLOOD WBC-9.4 RBC-5.11 Hgb-14.8 Hct-42.8 MCV-84 MCH-29.0 MCHC-34.6 RDW-11.9 RDWSD-36.2 Plt ___ ___ 04:45PM BLOOD Glucose-214* UreaN-12 Creat-0.6 Na-135 K-4.3 Cl-96 HCO3-27 AnGap-16 ___ 05:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9 ___ 04:53PM BLOOD Lactate-1.8 . On Discharge: ___ 09:15AM BLOOD WBC-7.1 RBC-4.89 Hgb-14.2 Hct-42.1 MCV-86 MCH-29.0 MCHC-33.7 RDW-12.0 RDWSD-37.6 Plt ___ ___ 09:15AM BLOOD Plt ___ ___ 09:15AM BLOOD Glucose-268* UreaN-14 Creat-0.6 Na-136 K-4.7 Cl-100 HCO3-24 AnGap-17 ___ 09:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 Imaging: Right Foot Xray ___: No acute fractures or dislocation are seen. There are no erosions. A small plantar calcaneal spur is noted. . Right Foot Xray ___: In comparison with study of ___, there has been resection of bone about the PIP joint of the second digit. . CXR ___: The cardiomediastinal and hilar contours are normal. Lungs are clear. There is no evidence of pulmonary edema, pleural effusion, or pneumothorax. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. . Microbiology: GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH . Pathology: Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE Procedure Date of ___ Report not finalized. Assigned Pathologist ___, MD ___ in only. PATHOLOGY # ___ BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE . Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on ___ for a R ___ toe infection. On admission, she was started on broad spectrum antibiotics. She was taken to the OR for Right ___ toe ulcer debridement and PIPJ arthroplasty on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. . Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. She was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with doxycycline. Her intake and output were closely monitored and noted to be adequtae. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. She worked with ___ during admission who recommended discharge home with partial weight bearing heel status. The patient was subsequently discharged to home on ___. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 80 mg PO DAILY 2. Gabapentin 600 mg PO BID 3. LORazepam 1 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 5. amLODIPine 10 mg PO DAILY 6. GlyBURIDE 10 mg PO BID 7. Losartan Potassium 50 mg PO DAILY 8. Pravastatin 20 mg PO QPM 9. Spironolactone 25 mg PO DAILY 10. Vitamin D 5000 UNIT PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 12. Carvedilol 12.5 mg PO BID 13. Citalopram 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H Disp #*30 Tablet Refills:*0 5. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 6 Units QID per sliding scale Disp #*1 Vial Refills:*2 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 7. amLODIPine 10 mg PO DAILY 8. Carvedilol 12.5 mg PO BID 9. Citalopram 40 mg PO DAILY 10. Furosemide 80 mg PO DAILY 11. Gabapentin 600 mg PO BID 12. GlyBURIDE 10 mg PO BID 13. LORazepam 1 mg PO BID 14. Losartan Potassium 50 mg PO DAILY 15. Pravastatin 20 mg PO QPM 16. Spironolactone 25 mg PO DAILY 17. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right ___ toe osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Requires assistance with can or crutches Discharge Instructions: It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service for treatment of your right foot infection. You were given IV antibiotics while here. You were taken to the OR on ___ for resection of infected bone. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weight bearing to the heel only on your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. WOUND CARE: Please leave the dressing to the Right Foot intact until your follow up appointment. Keep the Right Foot dry. If the dressing gets wet it must be changed. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
[ "M86171", "E11621", "E1142", "I110", "I509", "L97519", "I2510", "E785", "Z87891", "F329", "F419", "Z794", "E669", "Z6839" ]
Allergies: cephalexin / Bactrim Chief Complaint: Right [MASKED] toe infection Major Surgical or Invasive Procedure: [MASKED]: 1. Right Foot [MASKED] toe debridement 2. Right [MASKED] PIPJ arthroplasty History of Present Illness: Ms. [MASKED] is a [MASKED] with PMHx of DM c/b neuropathy, CHF, HTN presenting to the ED with c/o infection to the R [MASKED] toe. She has been on 2 courses of 10 days of clindamycin without improvement. Pt endorses some improvement while finishing clindamycin a few days ago but now with dark eschar, persistent redness/pain. She has some numbness at the bottom of her feet from chronic neuropathy but able to walk even with painful second toe. She was instructed by her PCP two weeks ago to see podiatry about this issue but did not because of insurance issues. She reports mild fevers / chills at home the last few days. No chest pain/SOB. Total body joint pain which is chronic for many years. Past Medical History: PAST MEDICAL HISTORY: DM (c/b peripheral neuropathy) Hyperlipidemia Obesity CAD (cardiac catheter in [MASKED]: Reports not available, gets CP rarely. Has seen dr [MASKED] in the past, cannot see Dr [MASKED] due to insurance issues) CHF HTN Anxiety/depression PAST SURGICAL HISTORY: hysterectomy Social History: [MASKED] Family History: Mother had diabetes and neuropathy. No family history of cancers or coronary disease. Her son just passed, they are doing an autopsy, unsure of cause of death. Her niece diagnosed with stage 4 melanoma, (it was her father who just died), not handling it well. Physical Exam: On Admission: VITALS: 97.3 71 137/68 16 99% RA GEN: NAD, AOx3 RESP: CTA ABD: obese, soft, [MASKED] FOCUSED: [MASKED] pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R [MASKED] toe. Mild peripheral edema noted. R 2md toe with ulceration to the dorsal aspect of the PIPJ with dry eschar covering, underlying fibrotic tissue with exposed bone. No purulence or fluctuance noted. R [MASKED] toe with erythema and warmth. hammertoe deformity to the [MASKED] toe b/l. mild pain with palpation of the ulcerated area. NEURO: light touch sensation diminished to the [MASKED] b/l. On Discharge: AVSS GEN: NAD, AOx3 CHEST: RRR RESP: CTA, no resp distress ABD: obese, soft, [MASKED], non-distended, no rebounding or guarding [MASKED] FOCUSED: [MASKED] pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R [MASKED] toe. Right [MASKED] digit sutures intact with no signs of dehiscence. Erythema improved. No drainage. No malodor. Mild peripheral edema noted. No TTP to the [MASKED] toe. No signs of any other open lesions. Able to wiggle all toes x 10 NEURO: light touch sensation diminished to the [MASKED] b/l. Pertinent Results: On Admission: [MASKED] 04:45PM BLOOD WBC-9.4 RBC-5.11 Hgb-14.8 Hct-42.8 MCV-84 MCH-29.0 MCHC-34.6 RDW-11.9 RDWSD-36.2 Plt [MASKED] [MASKED] 04:45PM BLOOD Glucose-214* UreaN-12 Creat-0.6 Na-135 K-4.3 Cl-96 HCO3-27 AnGap-16 [MASKED] 05:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9 [MASKED] 04:53PM BLOOD Lactate-1.8 . On Discharge: [MASKED] 09:15AM BLOOD WBC-7.1 RBC-4.89 Hgb-14.2 Hct-42.1 MCV-86 MCH-29.0 MCHC-33.7 RDW-12.0 RDWSD-37.6 Plt [MASKED] [MASKED] 09:15AM BLOOD Plt [MASKED] [MASKED] 09:15AM BLOOD Glucose-268* UreaN-14 Creat-0.6 Na-136 K-4.7 Cl-100 HCO3-24 AnGap-17 [MASKED] 09:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 Imaging: Right Foot Xray [MASKED]: No acute fractures or dislocation are seen. There are no erosions. A small plantar calcaneal spur is noted. . Right Foot Xray [MASKED]: In comparison with study of [MASKED], there has been resection of bone about the PIP joint of the second digit. . CXR [MASKED]: The cardiomediastinal and hilar contours are normal. Lungs are clear. There is no evidence of pulmonary edema, pleural effusion, or pneumothorax. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. . Microbiology: GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH . Pathology: Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE Procedure Date of [MASKED] Report not finalized. Assigned Pathologist [MASKED], MD [MASKED] in only. PATHOLOGY # [MASKED] BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE . Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on [MASKED] for a R [MASKED] toe infection. On admission, she was started on broad spectrum antibiotics. She was taken to the OR for Right [MASKED] toe ulcer debridement and PIPJ arthroplasty on [MASKED]. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. . Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. She was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with doxycycline. Her intake and output were closely monitored and noted to be adequtae. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. She worked with [MASKED] during admission who recommended discharge home with partial weight bearing heel status. The patient was subsequently discharged to home on [MASKED]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 80 mg PO DAILY 2. Gabapentin 600 mg PO BID 3. LORazepam 1 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 5. amLODIPine 10 mg PO DAILY 6. GlyBURIDE 10 mg PO BID 7. Losartan Potassium 50 mg PO DAILY 8. Pravastatin 20 mg PO QPM 9. Spironolactone 25 mg PO DAILY 10. Vitamin D 5000 UNIT PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 12. Carvedilol 12.5 mg PO BID 13. Citalopram 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H Disp #*30 Tablet Refills:*0 5. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 6 Units QID per sliding scale Disp #*1 Vial Refills:*2 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 7. amLODIPine 10 mg PO DAILY 8. Carvedilol 12.5 mg PO BID 9. Citalopram 40 mg PO DAILY 10. Furosemide 80 mg PO DAILY 11. Gabapentin 600 mg PO BID 12. GlyBURIDE 10 mg PO BID 13. LORazepam 1 mg PO BID 14. Losartan Potassium 50 mg PO DAILY 15. Pravastatin 20 mg PO QPM 16. Spironolactone 25 mg PO DAILY 17. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right [MASKED] toe osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Requires assistance with can or crutches Discharge Instructions: It was a pleasure taking care of you at [MASKED]. You were admitted to the Podiatric Surgery service for treatment of your right foot infection. You were given IV antibiotics while here. You were taken to the OR on [MASKED] for resection of infected bone. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weight bearing to the heel only on your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. WOUND CARE: Please leave the dressing to the Right Foot intact until your follow up appointment. Keep the Right Foot dry. If the dressing gets wet it must be changed. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next [MASKED] days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are [MASKED] through [MASKED]. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: [MASKED]
[]
[ "I110", "I2510", "E785", "Z87891", "F329", "F419", "Z794", "E669" ]
[ "M86171: Other acute osteomyelitis, right ankle and foot", "E11621: Type 2 diabetes mellitus with foot ulcer", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "L97519: Non-pressure chronic ulcer of other part of right foot with unspecified severity", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult" ]
10,066,039
24,763,357
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / morphine Attending: ___. Chief Complaint: humeral fracture, fall Major Surgical or Invasive Procedure: n/a History of Present Illness: The pt is a ___ year old female w/ htn, p/w trauma 1 day ago w/ resultant R humeral fracture, noted to have increased confusion and ? facial asymmetry after prolonged stay in the ED daughter states that pt fell at home on ___ night around 930pm. pt ambulates with walker. fall was unwitnessed. per pt, she fell onto her buttocks, no headtrike, but injured shoulder. She presented to ___. daughter states that OSH attempted several times to relocate shoulder unsuccessfully. pt with R knee pain, daughter states this is baseline, but pain has increased since fall. ROM affected due to pain. unclear if pain is in R hip or R knee. Upon transfer to ___ ED, initial vitals were: 97.7 72 181/73 18 95% RA Labs were notable for: Hgb 9.6 (last known baseline was 12.1 in ___ She was seen by Orthopedic surgery who recommended nonoperative management. She was being observed in the ED when over the course of the day ___, she was noted to be progressively more confused and disoriented. She was given olanzapine, with poor response. She was subsequently found to have mod leuk in her UA, and so was given nitrofurantoin. ED chart review reveals she has also received lorazepam and several doses of IV hydromorphone (presumably for her orthopedic pain). At around 11pm on ___, her daughter at bedside noticed her left eyelid was droopy. At that point a code stroke was called. Patient unable to provide history as she is confused and believes she is in a car by the park. According to her daughter, this is very different from her baseline, at ___ she is alert, oriented, and has no problems with her memory. She lives alone in an apartment but receives home care 5 hours/day and her children provide assistance as well. She has been confused for the most part of today and has been sleep deprived while in ED. She verbalizes that she wishes to go home repeatedly, believes she is in the park, and is progressively less redirectable. Past Medical History: Depression Hypertension Insomnia Anxiety Social History: ___ Family History: NC Physical Exam: ON ADMISSION: ================ Vitals: T: 97.9 BP: 140/70s P: 80s R: 18 O2: 96% RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. ON DISCHARGE: ============= Vitals: Tm 98.5 112-169/51-70 ___ 18 95%RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. Pertinent Results: ON ADMISSION: ============= ___ 01:48AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.6* Hct-30.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-13.8 RDWSD-46.9* Plt ___ ___ 01:48AM BLOOD Neuts-74.0* Lymphs-15.2* Monos-7.9 Eos-2.1 Baso-0.2 Im ___ AbsNeut-6.58* AbsLymp-1.35 AbsMono-0.70 AbsEos-0.19 AbsBaso-0.02 ___ 01:48AM BLOOD ___ PTT-27.5 ___ ___ 01:48AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-23 AnGap-14 ___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:00AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 02:00AM URINE RBC-2 WBC-26* Bacteri-FEW Yeast-NONE Epi-3 TransE-2 ___ 02:00AM URINE CastHy-1* ___ 02:00AM URINE Mucous-RARE PERTINENT LABS: ================ ___ 10:20AM BLOOD WBC-10.4* RBC-3.31* Hgb-9.8* Hct-30.5* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.8 RDWSD-46.7* Plt ___ ___ 08:15AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.6 MCHC-31.9* RDW-14.2 RDWSD-48.0* Plt ___ ___ 07:50AM BLOOD WBC-7.9 RBC-3.25* Hgb-9.4* Hct-30.4* MCV-94 MCH-28.9 MCHC-30.9* RDW-14.4 RDWSD-48.8* Plt ___ DISCHARGE LABS: =============== NOT OBTAINED ON DAY OF DISCHARGE MICRO: ========= ___ 4:00 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 2:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========== HEAD CT 1. No definitive acute intracranial abnormality on noncontrast head CT. There is no intracranial hemorrhage. 2. Nonspecific asymmetric hypodensity of the left pons is slightly more prominent on the current exam, which may be secondary to artifact. If there no contraindications, MRI would be more sensitive for acute infarcts. CT RIGHT SHOULDER 1. Minimally displaced right acromion fracture. 2. Fracture through the base of the coracoid process with 1.6 cm of anterior distraction of the bony fragment segment. 3. Mild anterior subluxation of the humeral head at the glenohumeral joint without frank dislocation. 4. Large subacromial and subcoracoid joint effusion. RIGHT SHOULDER X RAY Anterior glenohumeral dislocation. Fractures are better evaluated on subsequent CT shoulder. HIP/PELVIS X RAY Evaluation is limited by overlying soft tissues. No fracture or dislocation is seen. There is significant femoroacetabular joint space narrowing bilaterally, right greater than left. Evaluation of the sacrum is somewhat limited by overlying bowel gas. No radiopaque foreign body seen. IMPRESSION: Limited evaluation for fracture. If there is suspicion for fracture, cross-sectional imaging should be performed. RIGHT KNEE X-RAY: No fracture or dislocation is detected. There is narrowing in the medial compartment. Chondrocalcinosis is most prominent in the lateral compartment. No suspicious lytic or sclerotic lesion is identified. No joint effusion is seen. Vascular calcifications are seen. No radio-opaque foreign body is detected. The bones are demineralized. CT SPINE: Alignment is normal. No fractures are identified.There is no significant canal narrowing.There is no prevertebral edema. There are mild changes of degenerative disk disease without spinal canal or neural foraminal encroachment. There is diffuse osteopenia suggesting osteoporosis. The thyroid and included lung apices are unremarkable. IMPRESSION: No evidence of fracture or malalignment. Mild degenerative disc disease without canal or foraminal encroachment Brief Hospital Course: ___ yo ___ woman presenting with right humeral fracture s/p mechanical fall, found to have iatrogenic delirium and facial changes concerning for ?carotid dissection. # R anterior shoulder dislocation: not reducible, per discussion with pt's daughter, electing for nonoperative management and healing over ___ weeks. Pt will require rehab after discharge from hospital. She will follow up with Dr. ___ on ___. Her pain was managed with Tylenol. # AMS: most likely ___ iatrogenic delirium d/t administration of multiple sedatives and deliriogenic medications. Stroke/TIA less likely based on head CT and neuro exam. Found to have a positive UA with sx, so was treated for 3 days with IV CTX, but this medication was d/c'ed because her urine culture returned negative. Her home Ambien and Ativan were stopped. # Facial asymmetry: pt presented with miosis and eyelid droop on the right side, which is the same side as her humeral fracture. Head CT negative for acute changes. Neurology was consulted, and felt that her sx were likely due to a palpebral muscle dehiscence, so did not recommend further workup. The pt was started on 81 mg ASA for stroke ppx. ***Transitional issues***: - blood pressure was elevated to 169/70 on discharge, asymptomatic, continued home medication valsartan 160 BID, no further interventions, reevaluate if this is a persistent problem - stopped medications: pt was taken off home Ativan and Ambien due to concern for inducing delirium. She did not display anxiety or request sleep medications during her stay. - pain medications: started patient on Tylenol for pain management. She responded well to this. If needs further medications, consider low-dose Tramadol. - pt started on 81 mg ASA for stroke prophylaxis. - pt was started on antibiotics for presumed UTI and completed a 3 day course of Ceftriaxone - humeral fracture: pt will follow up with Dr. ___ on ___ for further management of humeral fracture and shoulder dislocation. She may wear shoulder sling for comfort. ***DNR/DNI*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO QAM 2. Valsartan 160 mg PO BID 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety 4. Zolpidem Tartrate 10 mg PO QHS insomnia 5. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN 6. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Artificial Tears 1 DROP BOTH EYES DAILY 9. Multivitamins 1 TAB PO DAILY 10. Bisacodyl ___ mg PO QHS Discharge Medications: 1. Artificial Tears 1 DROP BOTH EYES DAILY 2. Bisacodyl ___ mg PO QHS 3. Citalopram 10 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Valsartan 160 mg PO BID 7. Acetaminophen 650 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 11. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: - Minimally displaced right acromion and coracoid process fracture - Anterior right humeral head dislocation - Toxic-metabolic encephalopathy due to medications Secondary diagnoses: - Hypertension - Depression - Anxiety - Chronic back pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you dislocated your shoulder and broke your arm. Initially there was concern that you had a stroke, but our neurology team evaluated you and did not find evidence of one. You should follow up with Dr. ___ expect your arm to heal in ___ weeks. It was a pleasure taking care of you and we wish you the best at rehab! Sincerely, Your ___ team Followup Instructions: ___
[ "S42121A", "G92", "N390", "S43014A", "I10", "H02402", "H5703", "Z66", "F329", "F419", "S42131A", "W19XXXA", "Y92009" ]
Allergies: Penicillins / morphine Chief Complaint: humeral fracture, fall Major Surgical or Invasive Procedure: n/a History of Present Illness: The pt is a [MASKED] year old female w/ htn, p/w trauma 1 day ago w/ resultant R humeral fracture, noted to have increased confusion and ? facial asymmetry after prolonged stay in the ED daughter states that pt fell at home on [MASKED] night around 930pm. pt ambulates with walker. fall was unwitnessed. per pt, she fell onto her buttocks, no headtrike, but injured shoulder. She presented to [MASKED]. daughter states that OSH attempted several times to relocate shoulder unsuccessfully. pt with R knee pain, daughter states this is baseline, but pain has increased since fall. ROM affected due to pain. unclear if pain is in R hip or R knee. Upon transfer to [MASKED] ED, initial vitals were: 97.7 72 181/73 18 95% RA Labs were notable for: Hgb 9.6 (last known baseline was 12.1 in [MASKED] She was seen by Orthopedic surgery who recommended nonoperative management. She was being observed in the ED when over the course of the day [MASKED], she was noted to be progressively more confused and disoriented. She was given olanzapine, with poor response. She was subsequently found to have mod leuk in her UA, and so was given nitrofurantoin. ED chart review reveals she has also received lorazepam and several doses of IV hydromorphone (presumably for her orthopedic pain). At around 11pm on [MASKED], her daughter at bedside noticed her left eyelid was droopy. At that point a code stroke was called. Patient unable to provide history as she is confused and believes she is in a car by the park. According to her daughter, this is very different from her baseline, at [MASKED] she is alert, oriented, and has no problems with her memory. She lives alone in an apartment but receives home care 5 hours/day and her children provide assistance as well. She has been confused for the most part of today and has been sleep deprived while in ED. She verbalizes that she wishes to go home repeatedly, believes she is in the park, and is progressively less redirectable. Past Medical History: Depression Hypertension Insomnia Anxiety Social History: [MASKED] Family History: NC Physical Exam: ON ADMISSION: ================ Vitals: T: 97.9 BP: 140/70s P: 80s R: 18 O2: 96% RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. ON DISCHARGE: ============= Vitals: Tm 98.5 112-169/51-70 [MASKED] 18 95%RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. Pertinent Results: ON ADMISSION: ============= [MASKED] 01:48AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.6* Hct-30.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-13.8 RDWSD-46.9* Plt [MASKED] [MASKED] 01:48AM BLOOD Neuts-74.0* Lymphs-15.2* Monos-7.9 Eos-2.1 Baso-0.2 Im [MASKED] AbsNeut-6.58* AbsLymp-1.35 AbsMono-0.70 AbsEos-0.19 AbsBaso-0.02 [MASKED] 01:48AM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 01:48AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-23 AnGap-14 [MASKED] 02:00AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 02:00AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [MASKED] 02:00AM URINE RBC-2 WBC-26* Bacteri-FEW Yeast-NONE Epi-3 TransE-2 [MASKED] 02:00AM URINE CastHy-1* [MASKED] 02:00AM URINE Mucous-RARE PERTINENT LABS: ================ [MASKED] 10:20AM BLOOD WBC-10.4* RBC-3.31* Hgb-9.8* Hct-30.5* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.8 RDWSD-46.7* Plt [MASKED] [MASKED] 08:15AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.6 MCHC-31.9* RDW-14.2 RDWSD-48.0* Plt [MASKED] [MASKED] 07:50AM BLOOD WBC-7.9 RBC-3.25* Hgb-9.4* Hct-30.4* MCV-94 MCH-28.9 MCHC-30.9* RDW-14.4 RDWSD-48.8* Plt [MASKED] DISCHARGE LABS: =============== NOT OBTAINED ON DAY OF DISCHARGE MICRO: ========= [MASKED] 4:00 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 2:00 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========== HEAD CT 1. No definitive acute intracranial abnormality on noncontrast head CT. There is no intracranial hemorrhage. 2. Nonspecific asymmetric hypodensity of the left pons is slightly more prominent on the current exam, which may be secondary to artifact. If there no contraindications, MRI would be more sensitive for acute infarcts. CT RIGHT SHOULDER 1. Minimally displaced right acromion fracture. 2. Fracture through the base of the coracoid process with 1.6 cm of anterior distraction of the bony fragment segment. 3. Mild anterior subluxation of the humeral head at the glenohumeral joint without frank dislocation. 4. Large subacromial and subcoracoid joint effusion. RIGHT SHOULDER X RAY Anterior glenohumeral dislocation. Fractures are better evaluated on subsequent CT shoulder. HIP/PELVIS X RAY Evaluation is limited by overlying soft tissues. No fracture or dislocation is seen. There is significant femoroacetabular joint space narrowing bilaterally, right greater than left. Evaluation of the sacrum is somewhat limited by overlying bowel gas. No radiopaque foreign body seen. IMPRESSION: Limited evaluation for fracture. If there is suspicion for fracture, cross-sectional imaging should be performed. RIGHT KNEE X-RAY: No fracture or dislocation is detected. There is narrowing in the medial compartment. Chondrocalcinosis is most prominent in the lateral compartment. No suspicious lytic or sclerotic lesion is identified. No joint effusion is seen. Vascular calcifications are seen. No radio-opaque foreign body is detected. The bones are demineralized. CT SPINE: Alignment is normal. No fractures are identified.There is no significant canal narrowing.There is no prevertebral edema. There are mild changes of degenerative disk disease without spinal canal or neural foraminal encroachment. There is diffuse osteopenia suggesting osteoporosis. The thyroid and included lung apices are unremarkable. IMPRESSION: No evidence of fracture or malalignment. Mild degenerative disc disease without canal or foraminal encroachment Brief Hospital Course: [MASKED] yo [MASKED] woman presenting with right humeral fracture s/p mechanical fall, found to have iatrogenic delirium and facial changes concerning for ?carotid dissection. # R anterior shoulder dislocation: not reducible, per discussion with pt's daughter, electing for nonoperative management and healing over [MASKED] weeks. Pt will require rehab after discharge from hospital. She will follow up with Dr. [MASKED] on [MASKED]. Her pain was managed with Tylenol. # AMS: most likely [MASKED] iatrogenic delirium d/t administration of multiple sedatives and deliriogenic medications. Stroke/TIA less likely based on head CT and neuro exam. Found to have a positive UA with sx, so was treated for 3 days with IV CTX, but this medication was d/c'ed because her urine culture returned negative. Her home Ambien and Ativan were stopped. # Facial asymmetry: pt presented with miosis and eyelid droop on the right side, which is the same side as her humeral fracture. Head CT negative for acute changes. Neurology was consulted, and felt that her sx were likely due to a palpebral muscle dehiscence, so did not recommend further workup. The pt was started on 81 mg ASA for stroke ppx. ***Transitional issues***: - blood pressure was elevated to 169/70 on discharge, asymptomatic, continued home medication valsartan 160 BID, no further interventions, reevaluate if this is a persistent problem - stopped medications: pt was taken off home Ativan and Ambien due to concern for inducing delirium. She did not display anxiety or request sleep medications during her stay. - pain medications: started patient on Tylenol for pain management. She responded well to this. If needs further medications, consider low-dose Tramadol. - pt started on 81 mg ASA for stroke prophylaxis. - pt was started on antibiotics for presumed UTI and completed a 3 day course of Ceftriaxone - humeral fracture: pt will follow up with Dr. [MASKED] on [MASKED] for further management of humeral fracture and shoulder dislocation. She may wear shoulder sling for comfort. ***DNR/DNI*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO QAM 2. Valsartan 160 mg PO BID 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety 4. Zolpidem Tartrate 10 mg PO QHS insomnia 5. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN 6. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Artificial Tears 1 DROP BOTH EYES DAILY 9. Multivitamins 1 TAB PO DAILY 10. Bisacodyl [MASKED] mg PO QHS Discharge Medications: 1. Artificial Tears 1 DROP BOTH EYES DAILY 2. Bisacodyl [MASKED] mg PO QHS 3. Citalopram 10 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Valsartan 160 mg PO BID 7. Acetaminophen 650 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 11. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: - Minimally displaced right acromion and coracoid process fracture - Anterior right humeral head dislocation - Toxic-metabolic encephalopathy due to medications Secondary diagnoses: - Hypertension - Depression - Anxiety - Chronic back pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because you dislocated your shoulder and broke your arm. Initially there was concern that you had a stroke, but our neurology team evaluated you and did not find evidence of one. You should follow up with Dr. [MASKED] expect your arm to heal in [MASKED] weeks. It was a pleasure taking care of you and we wish you the best at rehab! Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N390", "I10", "Z66", "F329", "F419" ]
[ "S42121A: Displaced fracture of acromial process, right shoulder, initial encounter for closed fracture", "G92: Toxic encephalopathy", "N390: Urinary tract infection, site not specified", "S43014A: Anterior dislocation of right humerus, initial encounter", "I10: Essential (primary) hypertension", "H02402: Unspecified ptosis of left eyelid", "H5703: Miosis", "Z66: Do not resuscitate", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "S42131A: Displaced fracture of coracoid process, right shoulder, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,066,099
25,771,438
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cc:" I am glad I am alive" Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with no past psychiatric history who was brought to the hospital by EMS on ___ after disclosing to a friend that he had overdosed on acetaminophen (ingestion took place at ~21:00 on ___. Patient initially presented to ___ and there acetaminophen level was ~6 and NAC was initiated. He was transferred to ___ the early evening of ___ and admitted to the medical floor. Psychiatry is consulted for risk assessment in the setting of a suicide attempt. Patient reports that he has been feeling "depressed" and has been sleeping and eating poorly for the past few weeks. He states he sleeps "at the most 6 hours" each night. He is an ___ student at ___ and states that academic pressure has been mounting this semester. He remains in good academic standing, but says that he is "always behind" and describes his major's evaluation system as strict and very unpredictable. He said that prior to the ingestion, he had thoughts about "how it would be easier if it could all just be over" and took 100 500mg pills of acetaminophen with the intent of ending his life. He reports that shortly after the ingestion, he sent a message to one of his close friends to tell her what he did "because I didn't want to just leave everyone without saying anything". This friend notified the patient's mother and aunt, who then called ___. In addition to his academic stress, patient describes a recent legal problem he has encountered which became acutely distressing for him the day prior to this suicide attempt. Approximately three weeks ago, he states he found a debit card on the ground. He made some purchases with the card. On ___, he states that police came to his place of work and asked to speak with him about it. At that point, he explained what he had done and turned the card into the police. He reports that an officer "read me my rights" and had him sign a piece of paper at the time. He now is unsure what consequences/charges he may face because of this incident. After the ingestion, patient reports he vomited repeatedly (involuntarily) and experienced abdominal pain. "It's more work to leave than it is to stay". He states that he now feels "happy" that he did not die, and says "I have a lot to live for; I have a lot to look forward to." COLLATERAL: Source: Patient's mother, who accompanies him to the medical floor. Spoke with her separately from the patient. She reports that the patient has never had any mental health issues, and that this incident has been "a shock". She is not aware of any history of self harm or suicide attempts. She reports they have a large and very close family, and she feels that the patient has a lot of social support. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: None. Current treaters and treatment: None. Medication and ECT trials: None. Self-injury: As above. None prior to this attempt. Harm to others: Denies. Access to weapons: Denies. PAST MEDICAL HISTORY; denies Social History: ___ Family History: denies Physical Exam: ON ADMISSION: Vital Signs: T: 98.5 BP: 107 / 65 HR 65 RR 18 O2 sat 97 Ra GENERAL - HEENT: normocephalic, atraumatic, moist mucous membranes, oropharynx clear, supple neck, no scleral icterus - Cardiovascular:regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops, distal pulses intact - Pulmonary: lungs clear to auscultation bilaterally, no wheezes/rhonchi/rales, no increased work of breathing - Abdominal: soft, non-distended, bowel sounds normoactive, no TTP in all quadrants, no guarding, no rebound tenderness - Extremities: warm and well-perfused, no edema of the limbs - Skin: no rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - V: facial sensation intact to light touch in all distributions - VII: no facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally - VIII: hearing intact to finger rub bilaterally - IX, X: palate elevates symmetrically - XI: ___ strength in trapezii and SCM bilaterally - XII: tongue protrudes in midline - Motor: - normal bulk and tone bilaterally - no abnormal movements, no tremor - strength ___ throughout - Sensory: no deficits to fine touch throughout - DTRs: 2 and symmetrical throughout - Coordination: normal on finger to nose test, no intention tremor noted - Gait: good initiation, narrow-based, normal stride and arm swing, able to walk in tandem without difficulty, Romberg absent Mental Status Exam: Appearance: fair grooming Facial expression: neutral, shy looking build: WNL Behavior: engaging, addressing questions, cooperative Eye contact: direct psychomotor: no abnormal involuntary movements, no agitation Speech: normal rate, and tone Mood/affect "I am glad I am alive", sad, no irritability, anxious Thought Process/content: reality oriented, goal directed, denies SI in the unit, denies HI, denies AH/VH/paranoid delusions Intellectual Functioning: decreased concentration Oriented: x4 Memory: grossly intact insight: poor Judgment: poor ON DISCHARGE: Mental Status Exam: Appearance: well groomed, Facial expression: friendly, smiling on approach build: ___ Behavior: engaging, cooperative Eye contact: direct psychomotor: no abnormal involuntary movements, no agitation Speech: normal rate, and tone Mood/affect "OK", stable, much brighter, hopeful, Thought Process/content: reality oriented, goal directed, denies SI/HI, denies AH/VH/paranoid delusions Intellectual Functioning: fair concentration Oriented: x4 Memory: grossly intact insight: fair Judgment: fair Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct 7.1 5.50 14.7 41.1 75* 26.7 35.8 15.0 39.5 174 Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 141 3.9 95 24 ___. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: #) MDD, recurrent, severe, without psychotic features: Pt was admitted to the inpatient psychiatric unit on ___ (following 7 day medical hospitalization from ___ after overdose on 100 tabs of Tylenol, ___ mg each. On initial interview in emergency department on ___, pt reported that he had been feeling depressed with poor sleep and minimal appetite due to academic pressure at school. This led to the development of suicidal thoughts and pt reported overdosing on Tylenol with the intent to end his life. After medical stabilization and presentation to the inpatient psych unit, pt reported that he felt happy to be alive and that he felt he had a lot to live for. He was noted to be pleasant and engaging on initial presentation to the unit. He was started on Zoloft 25 mg daily which was uptitrated to 50 mg daily during his hospital stay. Pt denies experiencing any side effects from this medication. He note significant improvement in his mood and sleep. Reported feeling more hopeful, less anxious, and also noted an improvement in his energy level and appetite. He was noted to have a brighter affect and to be more insightful. On day of discharge, pt voiced no complaints was agreeable to discharge, appeared bright, displayed forward-thinking. 3. MEDICAL No acute issues during hospitalization. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. He was appropriate and pleasant in the milieu. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Treatment team remained in contact with pt's mother throughout hospitalization with pt's consent. She came to inpatient psych unit to meet with treatment team on several occasions to receive clinical updates and assist in discharge planning. #) INTERVENTIONS - Medications: Zoloft 50 mg - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: pt was set up with outpatient psychiatry and therapy appointments - Behavioral Interventions: reinforced coping skills, mindfulness, socialization INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself and/or others based upon recent suicide attempt with stated intent to end his life. His static factors noted at that time included recent suicide attempt, male gender, age and single status. The modifiable risk factors at that time included depressed mood with hopelessness, no established outpatient psychiatric providers, poor sleep, and suicidal ideation. These factors were addressed by individual, group, and milieu therapy, initiation of antidepressant medication, and connection with outpatient therapist and psychiatrist. Finally, the patient is being discharged with many protective risk factors, including help-seeking nature, future-oriented viewpoint, support from mother, life satisfaction, medication compliance, no history of substance use. Overall, the patient is not at an acutely elevated risk of self-harm nor danger to others due to acutely decompensated psychiatric illness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Major Depressive Disorder severe, no psychotic features Anxiety nos Discharge Condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory, independent Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___
[ "F322", "F419", "Z915" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: cc:" I am glad I am alive" Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] with no past psychiatric history who was brought to the hospital by EMS on [MASKED] after disclosing to a friend that he had overdosed on acetaminophen (ingestion took place at ~21:00 on [MASKED]. Patient initially presented to [MASKED] and there acetaminophen level was ~6 and NAC was initiated. He was transferred to [MASKED] the early evening of [MASKED] and admitted to the medical floor. Psychiatry is consulted for risk assessment in the setting of a suicide attempt. Patient reports that he has been feeling "depressed" and has been sleeping and eating poorly for the past few weeks. He states he sleeps "at the most 6 hours" each night. He is an [MASKED] student at [MASKED] and states that academic pressure has been mounting this semester. He remains in good academic standing, but says that he is "always behind" and describes his major's evaluation system as strict and very unpredictable. He said that prior to the ingestion, he had thoughts about "how it would be easier if it could all just be over" and took 100 500mg pills of acetaminophen with the intent of ending his life. He reports that shortly after the ingestion, he sent a message to one of his close friends to tell her what he did "because I didn't want to just leave everyone without saying anything". This friend notified the patient's mother and aunt, who then called [MASKED]. In addition to his academic stress, patient describes a recent legal problem he has encountered which became acutely distressing for him the day prior to this suicide attempt. Approximately three weeks ago, he states he found a debit card on the ground. He made some purchases with the card. On [MASKED], he states that police came to his place of work and asked to speak with him about it. At that point, he explained what he had done and turned the card into the police. He reports that an officer "read me my rights" and had him sign a piece of paper at the time. He now is unsure what consequences/charges he may face because of this incident. After the ingestion, patient reports he vomited repeatedly (involuntarily) and experienced abdominal pain. "It's more work to leave than it is to stay". He states that he now feels "happy" that he did not die, and says "I have a lot to live for; I have a lot to look forward to." COLLATERAL: Source: Patient's mother, who accompanies him to the medical floor. Spoke with her separately from the patient. She reports that the patient has never had any mental health issues, and that this incident has been "a shock". She is not aware of any history of self harm or suicide attempts. She reports they have a large and very close family, and she feels that the patient has a lot of social support. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: None. Current treaters and treatment: None. Medication and ECT trials: None. Self-injury: As above. None prior to this attempt. Harm to others: Denies. Access to weapons: Denies. PAST MEDICAL HISTORY; denies Social History: [MASKED] Family History: denies Physical Exam: ON ADMISSION: Vital Signs: T: 98.5 BP: 107 / 65 HR 65 RR 18 O2 sat 97 Ra GENERAL - HEENT: normocephalic, atraumatic, moist mucous membranes, oropharynx clear, supple neck, no scleral icterus - Cardiovascular:regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops, distal pulses intact - Pulmonary: lungs clear to auscultation bilaterally, no wheezes/rhonchi/rales, no increased work of breathing - Abdominal: soft, non-distended, bowel sounds normoactive, no TTP in all quadrants, no guarding, no rebound tenderness - Extremities: warm and well-perfused, no edema of the limbs - Skin: no rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - V: facial sensation intact to light touch in all distributions - VII: no facial droop, facial musculature symmetric and [MASKED] strength in upper and lower distributions, bilaterally - VIII: hearing intact to finger rub bilaterally - IX, X: palate elevates symmetrically - XI: [MASKED] strength in trapezii and SCM bilaterally - XII: tongue protrudes in midline - Motor: - normal bulk and tone bilaterally - no abnormal movements, no tremor - strength [MASKED] throughout - Sensory: no deficits to fine touch throughout - DTRs: 2 and symmetrical throughout - Coordination: normal on finger to nose test, no intention tremor noted - Gait: good initiation, narrow-based, normal stride and arm swing, able to walk in tandem without difficulty, Romberg absent Mental Status Exam: Appearance: fair grooming Facial expression: neutral, shy looking build: WNL Behavior: engaging, addressing questions, cooperative Eye contact: direct psychomotor: no abnormal involuntary movements, no agitation Speech: normal rate, and tone Mood/affect "I am glad I am alive", sad, no irritability, anxious Thought Process/content: reality oriented, goal directed, denies SI in the unit, denies HI, denies AH/VH/paranoid delusions Intellectual Functioning: decreased concentration Oriented: x4 Memory: grossly intact insight: poor Judgment: poor ON DISCHARGE: Mental Status Exam: Appearance: well groomed, Facial expression: friendly, smiling on approach build: [MASKED] Behavior: engaging, cooperative Eye contact: direct psychomotor: no abnormal involuntary movements, no agitation Speech: normal rate, and tone Mood/affect "OK", stable, much brighter, hopeful, Thought Process/content: reality oriented, goal directed, denies SI/HI, denies AH/VH/paranoid delusions Intellectual Functioning: fair concentration Oriented: x4 Memory: grossly intact insight: fair Judgment: fair Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct 7.1 5.50 14.7 41.1 75* 26.7 35.8 15.0 39.5 174 Glucose UreaN Creat Na K Cl HCO3 AnGap [MASKED] 141 3.9 95 24 [MASKED]. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: #) MDD, recurrent, severe, without psychotic features: Pt was admitted to the inpatient psychiatric unit on [MASKED] (following 7 day medical hospitalization from [MASKED] after overdose on 100 tabs of Tylenol, [MASKED] mg each. On initial interview in emergency department on [MASKED], pt reported that he had been feeling depressed with poor sleep and minimal appetite due to academic pressure at school. This led to the development of suicidal thoughts and pt reported overdosing on Tylenol with the intent to end his life. After medical stabilization and presentation to the inpatient psych unit, pt reported that he felt happy to be alive and that he felt he had a lot to live for. He was noted to be pleasant and engaging on initial presentation to the unit. He was started on Zoloft 25 mg daily which was uptitrated to 50 mg daily during his hospital stay. Pt denies experiencing any side effects from this medication. He note significant improvement in his mood and sleep. Reported feeling more hopeful, less anxious, and also noted an improvement in his energy level and appetite. He was noted to have a brighter affect and to be more insightful. On day of discharge, pt voiced no complaints was agreeable to discharge, appeared bright, displayed forward-thinking. 3. MEDICAL No acute issues during hospitalization. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. He was appropriate and pleasant in the milieu. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Treatment team remained in contact with pt's mother throughout hospitalization with pt's consent. She came to inpatient psych unit to meet with treatment team on several occasions to receive clinical updates and assist in discharge planning. #) INTERVENTIONS - Medications: Zoloft 50 mg - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: pt was set up with outpatient psychiatry and therapy appointments - Behavioral Interventions: reinforced coping skills, mindfulness, socialization INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself and/or others based upon recent suicide attempt with stated intent to end his life. His static factors noted at that time included recent suicide attempt, male gender, age and single status. The modifiable risk factors at that time included depressed mood with hopelessness, no established outpatient psychiatric providers, poor sleep, and suicidal ideation. These factors were addressed by individual, group, and milieu therapy, initiation of antidepressant medication, and connection with outpatient therapist and psychiatrist. Finally, the patient is being discharged with many protective risk factors, including help-seeking nature, future-oriented viewpoint, support from mother, life satisfaction, medication compliance, no history of substance use. Overall, the patient is not at an acutely elevated risk of self-harm nor danger to others due to acutely decompensated psychiatric illness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Major Depressive Disorder severe, no psychotic features Anxiety nos Discharge Condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory, independent Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]
[]
[ "F419" ]
[ "F322: Major depressive disorder, single episode, severe without psychotic features", "F419: Anxiety disorder, unspecified", "Z915: Personal history of self-harm" ]
10,066,099
28,039,632
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ male with no past medical history who presents as a transfer from ___ due to a Tylenol ingestion with intent of suicide attempt at 9:00 last night. Next The patient is a sophomore at the ___. He is studying architecture, which he enjoys. However, over the past several months, he has felt overwhelmed with his course load. He reports he is sleeping less ___ hours of sleep at night), and has not had time for things he previously enjoyed (working out at the gym, spending time with friends). Despite his attempts at keeping himself working, he feels he is falling behind. He states that "no matter what I do, it's not good enough" for his ___ professor. Compounding this is the fact that he is worried about some legal trouble. He states that he found a debit card on the ground recently, which was not his (and he did not know the owner). He ended up using the debit card to make some purchases for a few items. Lately, he states that he has been being pursued by the card owner who is coming after him for these unauthorized purchases. He does not believe that this episode was reported to the police, but he did say that somebody "read [him his] ___ rights" over these purchases. He is worried that this will cause him to lose his scholarships at ___, as he values his work at school and does not want to lose these opportunities. At ___, Pt was found to have LFTs of AST 79 and ALT 89 was started on ___. He received first loading dose and was receiving 2nd dose en route. He was transferred to ___ for liver transplant evaluation if necessary. Past Medical History: None Social History: ___ Family History: Hypertension and diabetes. Two cousins with early-onset breast cancer in their ___. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: ___ Temp: 98.8 PO BP: 126/73 L Lying HR: 77 RR: 20 O2 sat: 99% O2 delivery: Ra GENERAL: Interactive black male, lying in bed with somewhat sad affect. In no acute distress. HEENT: Sclerae anicteric, 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. No dullness or hyperresonance to percussion. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No hepatomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. +2 posterior tibialis pulses bilaterally. NEUROLOGIC: CN II-XII grossly intact. AOx3. There is no asterixis or pronator drift. DISCHARGE PHYSICAL EXAM ======================= 24 HR Data (last updated ___ @ 1245) Temp: 98.7 (Tm 98.7), BP: 101/60 (101-114/60-71), HR: 81 (64-81), RR: 18 (___), O2 sat: 99% (97-100), O2 delivery: Ra GENERAL: Awake, alert, comfortable CARDIAC: RRR, normal s1/s2, no murmurs LUNGS: Comfortable on room air ABDOMEN: Nontender, nondistended PSYCH: normal affect Pertinent Results: ADMISSION LABS =============== ___ 04:20PM BLOOD WBC-9.1 RBC-4.82 Hgb-12.9* Hct-40.0 MCV-83 MCH-26.8 MCHC-32.3 RDW-14.2 RDWSD-43.1 Plt ___ ___ 04:20PM BLOOD Neuts-49 Bands-0 ___ Monos-10 Eos-0 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-4.46 AbsLymp-3.73* AbsMono-0.91* AbsEos-0.00* AbsBaso-0.00* ___ 04:20PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 04:20PM BLOOD ___ PTT-28.3 ___ ___ 04:20PM BLOOD Plt Smr-NORMAL Plt ___ ___ 04:20PM BLOOD Glucose-132* UreaN-8 Creat-0.9 Na-141 K-3.9 Cl-102 HCO3-23 AnGap-16 ___ 04:20PM BLOOD ALT-79* AST-66* AlkPhos-70 TotBili-0.5 ___ 04:20PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.2 Mg-2.0 ___ 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 12:00AM BLOOD Acetmnp-NEG ___ 04:40PM BLOOD Lactate-1.1 DISCHARGE LABS ============== ___ 08:10AM BLOOD WBC-7.3 RBC-4.94 Hgb-13.3* Hct-41.0 MCV-83 MCH-26.9 MCHC-32.4 RDW-13.9 RDWSD-41.9 Plt ___ ___ 08:08AM BLOOD ___ PTT-29.1 ___ ___ 08:10AM BLOOD Glucose-88 UreaN-12 Creat-1.0 Na-142 K-4.4 Cl-103 HCO3-26 AnGap-13 ___ 08:08AM BLOOD ALT-248* AST-165* AlkPhos-81 TotBili-0.___RIEF HOSPITAL SUMMARY ====================== ___ is a ___ man with no past medical history who presented after a suicide attempt by ingesting Tylenol ___ (50g Acetaminophen + 2.5g Diphenhydramine). NAC was initiated 16 hours later and his acetaminophen level was normal at 20 hours. He as placed on a section 12a hold and was treated with NAC for several days until his LFTs downtrended. He was then discharged to an inpatient psychiatric facility. ACTIVE ISSUES ============= # ACETAMINOPHEN OVERDOSE # DIPHENHYDRAMINE OVERDOSE Known ingestion time 9PM on ___, NAC started 16h later 1PM on ___. He was persistently asymptomatic with no abdominal pain, nausea, vomiting, and with no signs of anticholinergic toxicity. His acetaminophen level was negative approximately 20 hours after time of ingestion and his INR was persistently normal. NAC was continued until his LFTs downtrended. # SUICIDE ATTEMPT Likely in setting of significant social stressors, legal concern, and poor social support (no friends he talks to routinely). First episode with no prior attempts. He did meet some SIGECAPS criteria for major depression (sleep changes, decreased appetite, suicidal ideation, difficulty concentrating) but given the acute time course it was difficult to rule out adjustment disorder. Psychiatry was consulted and placed a section 12a hold on admission. He persistently denied SI/HI throughout his hospitalization, appeared of normal affect, and reported a good mood. On discharge he was transferred to an inpatient psychiatric facility. #CODE: Full (confirmed with patient) #CONTACT: Mother, ___ (___) ___ on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSES ================= # ACETAMINOPHEN OVERDOSE # DIPHENHYDRAMINE OVERDOSE # SUICIDE ATTEMPT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was our pleasure to care for you at ___. You came to the hospital because of a Tylenol overdose. WHAT HAPPENED IN THE HOSPITAL? - We treated you with a medication called NAC and watched while your liver improved. - Our psychiatry team evaluated you and felt that you would be safest receiving inpatient psychiatric treatment. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? We wish you the best! Sincerely, Your care team at ___ Followup Instructions: ___
[ "T391X2A", "F322", "T450X2A", "Y92039", "Z608", "Z653", "Z23" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] male with no past medical history who presents as a transfer from [MASKED] due to a Tylenol ingestion with intent of suicide attempt at 9:00 last night. Next The patient is a sophomore at the [MASKED]. He is studying architecture, which he enjoys. However, over the past several months, he has felt overwhelmed with his course load. He reports he is sleeping less [MASKED] hours of sleep at night), and has not had time for things he previously enjoyed (working out at the gym, spending time with friends). Despite his attempts at keeping himself working, he feels he is falling behind. He states that "no matter what I do, it's not good enough" for his [MASKED] professor. Compounding this is the fact that he is worried about some legal trouble. He states that he found a debit card on the ground recently, which was not his (and he did not know the owner). He ended up using the debit card to make some purchases for a few items. Lately, he states that he has been being pursued by the card owner who is coming after him for these unauthorized purchases. He does not believe that this episode was reported to the police, but he did say that somebody "read [him his] [MASKED] rights" over these purchases. He is worried that this will cause him to lose his scholarships at [MASKED], as he values his work at school and does not want to lose these opportunities. At [MASKED], Pt was found to have LFTs of AST 79 and ALT 89 was started on [MASKED]. He received first loading dose and was receiving 2nd dose en route. He was transferred to [MASKED] for liver transplant evaluation if necessary. Past Medical History: None Social History: [MASKED] Family History: Hypertension and diabetes. Two cousins with early-onset breast cancer in their [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: [MASKED] Temp: 98.8 PO BP: 126/73 L Lying HR: 77 RR: 20 O2 sat: 99% O2 delivery: Ra GENERAL: Interactive black male, lying in bed with somewhat sad affect. In no acute distress. HEENT: Sclerae anicteric, 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. No dullness or hyperresonance to percussion. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No hepatomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. +2 posterior tibialis pulses bilaterally. NEUROLOGIC: CN II-XII grossly intact. AOx3. There is no asterixis or pronator drift. DISCHARGE PHYSICAL EXAM ======================= 24 HR Data (last updated [MASKED] @ 1245) Temp: 98.7 (Tm 98.7), BP: 101/60 (101-114/60-71), HR: 81 (64-81), RR: 18 ([MASKED]), O2 sat: 99% (97-100), O2 delivery: Ra GENERAL: Awake, alert, comfortable CARDIAC: RRR, normal s1/s2, no murmurs LUNGS: Comfortable on room air ABDOMEN: Nontender, nondistended PSYCH: normal affect Pertinent Results: ADMISSION LABS =============== [MASKED] 04:20PM BLOOD WBC-9.1 RBC-4.82 Hgb-12.9* Hct-40.0 MCV-83 MCH-26.8 MCHC-32.3 RDW-14.2 RDWSD-43.1 Plt [MASKED] [MASKED] 04:20PM BLOOD Neuts-49 Bands-0 [MASKED] Monos-10 Eos-0 Baso-0 Atyps-3* [MASKED] Myelos-0 AbsNeut-4.46 AbsLymp-3.73* AbsMono-0.91* AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:20PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [MASKED] 04:20PM BLOOD [MASKED] PTT-28.3 [MASKED] [MASKED] 04:20PM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 04:20PM BLOOD Glucose-132* UreaN-8 Creat-0.9 Na-141 K-3.9 Cl-102 HCO3-23 AnGap-16 [MASKED] 04:20PM BLOOD ALT-79* AST-66* AlkPhos-70 TotBili-0.5 [MASKED] 04:20PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.2 Mg-2.0 [MASKED] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 12:00AM BLOOD Acetmnp-NEG [MASKED] 04:40PM BLOOD Lactate-1.1 DISCHARGE LABS ============== [MASKED] 08:10AM BLOOD WBC-7.3 RBC-4.94 Hgb-13.3* Hct-41.0 MCV-83 MCH-26.9 MCHC-32.4 RDW-13.9 RDWSD-41.9 Plt [MASKED] [MASKED] 08:08AM BLOOD [MASKED] PTT-29.1 [MASKED] [MASKED] 08:10AM BLOOD Glucose-88 UreaN-12 Creat-1.0 Na-142 K-4.4 Cl-103 HCO3-26 AnGap-13 [MASKED] 08:08AM BLOOD ALT-248* AST-165* AlkPhos-81 TotBili-0. RIEF HOSPITAL SUMMARY ====================== [MASKED] is a [MASKED] man with no past medical history who presented after a suicide attempt by ingesting Tylenol [MASKED] (50g Acetaminophen + 2.5g Diphenhydramine). NAC was initiated 16 hours later and his acetaminophen level was normal at 20 hours. He as placed on a section 12a hold and was treated with NAC for several days until his LFTs downtrended. He was then discharged to an inpatient psychiatric facility. ACTIVE ISSUES ============= # ACETAMINOPHEN OVERDOSE # DIPHENHYDRAMINE OVERDOSE Known ingestion time 9PM on [MASKED], NAC started 16h later 1PM on [MASKED]. He was persistently asymptomatic with no abdominal pain, nausea, vomiting, and with no signs of anticholinergic toxicity. His acetaminophen level was negative approximately 20 hours after time of ingestion and his INR was persistently normal. NAC was continued until his LFTs downtrended. # SUICIDE ATTEMPT Likely in setting of significant social stressors, legal concern, and poor social support (no friends he talks to routinely). First episode with no prior attempts. He did meet some SIGECAPS criteria for major depression (sleep changes, decreased appetite, suicidal ideation, difficulty concentrating) but given the acute time course it was difficult to rule out adjustment disorder. Psychiatry was consulted and placed a section 12a hold on admission. He persistently denied SI/HI throughout his hospitalization, appeared of normal affect, and reported a good mood. On discharge he was transferred to an inpatient psychiatric facility. #CODE: Full (confirmed with patient) #CONTACT: Mother, [MASKED] ([MASKED]) [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSES ================= # ACETAMINOPHEN OVERDOSE # DIPHENHYDRAMINE OVERDOSE # SUICIDE ATTEMPT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was our pleasure to care for you at [MASKED]. You came to the hospital because of a Tylenol overdose. WHAT HAPPENED IN THE HOSPITAL? - We treated you with a medication called NAC and watched while your liver improved. - Our psychiatry team evaluated you and felt that you would be safest receiving inpatient psychiatric treatment. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? We wish you the best! Sincerely, Your care team at [MASKED] Followup Instructions: [MASKED]
[]
[]
[ "T391X2A: Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter", "F322: Major depressive disorder, single episode, severe without psychotic features", "T450X2A: Poisoning by antiallergic and antiemetic drugs, intentional self-harm, initial encounter", "Y92039: Unspecified place in apartment as the place of occurrence of the external cause", "Z608: Other problems related to social environment", "Z653: Problems related to other legal circumstances", "Z23: Encounter for immunization" ]
10,066,149
20,842,875
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p motor vehicle collision Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ who presents to ___ ED on ___ s/p MVC into 2 telephone poles found to have left temporal bone fracture and R posterior parietal fracture with small amount of adjacent pneumocephalus and exceedinly small R apical pneumothorax as seen on CT Chest. Patient was an intoxicated driver of the vehicle. Serum ETOH 193 on arrival to ED. Patient reports he was wearing his seatbelt. Denies LOC however is unable to describe mechanism of injury and unsure if patient is accurate historian. Reports posterior headache. No visual changes. Denies CP/SOB, abdominal pain, N/V/D, fevers/chills. Past Medical History: PMH: diabetes mellitus Type 2 PSH: - s/p L knee ORIF for comminuted L tibial fracture s/p motorcycle accident ___ Social History: ___ Family History: reviewed and noncontributory Physical Exam: Admission Physical Exam: Vitals: 98.2 BP: 102/78 HR: 110 RR: 21 O2 Sat: 98%RA Gen: A&Ox3, in NAD HEENT: Multiple abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, 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: 99.7 99.2 99 123/74 18 96% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: several well-healing abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, 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: ============== ADMISSION LABS ============== ___ 04:25AM BLOOD WBC-19.1* RBC-4.86 Hgb-14.5 Hct-43.7 MCV-90 MCH-29.8 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt ___ ___ 04:25AM BLOOD ___ PTT-22.6* ___ ___ 04:25AM BLOOD Lipase-38 ___ 04:25AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:33AM BLOOD Glucose-254* Lactate-2.9* Na-143 K-3.7 Cl-106 calHCO3-24 ======== IMAGING ======== ___ CXR: IMPRESSION: Tiny right pneumothorax seen on CT chest is not visualized on radiograph. ___ CT Head w/o contrast: IMPRESSION: 1. Complex calvarial fracture, including a transversely oriented occipital bone fracture extending from the right occipital/mastoid suture through the occipital bone and into the left mastoid, and a right parasagittal occipital bone fracture. 2. 3 mm extra-axial hematoma along the left occipital and posterior temporal lobes, contiguous with the left transverse sinus. Possible additional 3 mm extra-axial hematoma in the left posterior fossa contiguous with the transverse sinus, versus asymmetric appearance of the left sigmoid sinus. 3. Partial opacification of left superior mastoid air cells, likely hemorrhagic given the left mastoid fracture. 4. Periapical lucency ___ 3. Please correlate clinically whether active dental inflammation may be present. RECOMMENDATION(S): 1. CT venogram to assess patency of the left transverse sinus. 2. Temporal bone CT for better assessment of left inner ear and middle ear structures. ___ CT C spine: IMPRESSION: No cervical spine fracture or malalignment. ___ CT Chest/Abdomen/Pelvis with contrast: IMPRESSION: 1. Tiny right pneumothorax. 2. No acute trauma in the abdomen or pelvis. ___ CT orbit/sella/IAC w/o contrast: IMPRESSION: 1. Fracture of the occipital bone, longitudinal fractures of the left temporal bone. No fractures of the right temple bone. 2. Opacified left mastoids, middle ear cavity. 3. The known extra-axial hematoma about torcula and venous sinuses are better seen on the same-day CT venogram exam. ___ CT Head venogram: IMPRESSION: 1. Extra-axial hematoma along the posterior margin of the superior sagittal, and medial bilateral transverse sinuses causing moderate to severe narrowing of sinuses, without occlusion few air locule is within the sinus, likely related to left temporal bone fractures. No change in the size of hematoma. Consider venous sinus injury as source of hemorrhage, close imaging follow-up recommended. 2. Stable acute occipital bone, left temporal bone fractures. Brief Hospital Course: Mr. ___ was admitted to the Acute Care Surgery Service under the care of Dr. ___ for further assessment and clinical management of his injuries following his motor vehicle collision. His initial injuries identified during his work up in the Emergency department included a left temporal skull fracture with associated pneumocephalus as well as an exceedingly small right pneumothorax without any associated rib fractures. He was evaluated by the the Neurosurgery Service regarding his skull fracture and pneumocephalus and given that he had no associated neurologic sequelae, it was decided that he did not require any surgical intervention. He underwent additional imaging at the suggestion of the Radiology Department to further characterize intracranial structures not well seen on initial imaging - a CT venogram identified moderately to severely narrowed bilateral transverse sinuses possibly resulting from compression via his extra-cranial hematoma. A Neurology consult was obtained to assess the need for possible anticoagulation as prophylaxis in the setting of stenosis - it was deemed that he did not require any anticoagulation as this imaging finding may have been related to chronic hypoplastic transverse sinuses. It was instead recommended that he undergo repeat imaging and revisit in the Neurology/Stroke Clinic in ___ weeks to assess stability of the narrowing as well as possible progression of any neurologic symptoms. On the evening of HD2, the patient was tolerating a regular diet, voiding and ambulating without difficulty, his pain was well controlled with PO pain medications, his wounds were clean, dry and intact without any evidence of infection, and he remained afebrile, hemodynamically stable, and neurologically intact. He was thus deemed ready for discharge home with follow up in the Acute Care Surgery Clinic in 2 weeks and was instructed to contact the Neuro/Stroke Center to undergo repeat CT venogram and follow up visit. The patient expressed understanding and agreed to the aforementioned plan at the time of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 4000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*0 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Do not drink or drive while taking. Please discard extra. RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp #*10 Tablet Refills:*0 4. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: left temporal bone fracture pneumocephalus possible hypoplastic transverse sinus right pneumothorax 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 ___ for close monitoring following a motor vehicle accident after your Emergency Room imaging confirmed that you sustained a skull fracture and air inside your skull (pneumocephalus), which can be dangerous. You were seen by the Neurosurgery Service who determined that you did not have any injuries that required surgery. You did have additional CAT scans of your head that showed narrowed veings in the brain that were concerning for high risk of blood clot in the brain (venous thrombosis). Neurology determined that you do not need any blood thinners for this, but recommended that you follow up in the Neuro/Stroke Clinic with repeat CAT scan to make sure you're recovering well. Additionally, your imaging showed a very small amount of air in your lung cavity (pneumothorax). This resolved on its own after repeat your chest xray the following day and you did not require any additional interventions. You will be seen in Acute Care Surgery Clinic to make sure you are recovering well from your overall trauma. You are now ready to be discharged home. Please see below for additional 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. *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. Pain control: * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. Thank you very much for the opportunity to participate in your care. Best wishes for a speedy recovery! Followup Instructions: ___
[ "S0219XA", "S020XXA", "G9389", "J939", "M25562", "V475XXA", "Y929", "F10129", "R7303", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p motor vehicle collision Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] who presents to [MASKED] ED on [MASKED] s/p MVC into 2 telephone poles found to have left temporal bone fracture and R posterior parietal fracture with small amount of adjacent pneumocephalus and exceedinly small R apical pneumothorax as seen on CT Chest. Patient was an intoxicated driver of the vehicle. Serum ETOH 193 on arrival to ED. Patient reports he was wearing his seatbelt. Denies LOC however is unable to describe mechanism of injury and unsure if patient is accurate historian. Reports posterior headache. No visual changes. Denies CP/SOB, abdominal pain, N/V/D, fevers/chills. Past Medical History: PMH: diabetes mellitus Type 2 PSH: - s/p L knee ORIF for comminuted L tibial fracture s/p motorcycle accident [MASKED] Social History: [MASKED] Family History: reviewed and noncontributory Physical Exam: Admission Physical Exam: Vitals: 98.2 BP: 102/78 HR: 110 RR: 21 O2 Sat: 98%RA Gen: A&Ox3, in NAD HEENT: Multiple abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, 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: 99.7 99.2 99 123/74 18 96% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: several well-healing abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, 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: ============== ADMISSION LABS ============== [MASKED] 04:25AM BLOOD WBC-19.1* RBC-4.86 Hgb-14.5 Hct-43.7 MCV-90 MCH-29.8 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt [MASKED] [MASKED] 04:25AM BLOOD [MASKED] PTT-22.6* [MASKED] [MASKED] 04:25AM BLOOD Lipase-38 [MASKED] 04:25AM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 04:33AM BLOOD Glucose-254* Lactate-2.9* Na-143 K-3.7 Cl-106 calHCO3-24 ======== IMAGING ======== [MASKED] CXR: IMPRESSION: Tiny right pneumothorax seen on CT chest is not visualized on radiograph. [MASKED] CT Head w/o contrast: IMPRESSION: 1. Complex calvarial fracture, including a transversely oriented occipital bone fracture extending from the right occipital/mastoid suture through the occipital bone and into the left mastoid, and a right parasagittal occipital bone fracture. 2. 3 mm extra-axial hematoma along the left occipital and posterior temporal lobes, contiguous with the left transverse sinus. Possible additional 3 mm extra-axial hematoma in the left posterior fossa contiguous with the transverse sinus, versus asymmetric appearance of the left sigmoid sinus. 3. Partial opacification of left superior mastoid air cells, likely hemorrhagic given the left mastoid fracture. 4. Periapical lucency [MASKED] 3. Please correlate clinically whether active dental inflammation may be present. RECOMMENDATION(S): 1. CT venogram to assess patency of the left transverse sinus. 2. Temporal bone CT for better assessment of left inner ear and middle ear structures. [MASKED] CT C spine: IMPRESSION: No cervical spine fracture or malalignment. [MASKED] CT Chest/Abdomen/Pelvis with contrast: IMPRESSION: 1. Tiny right pneumothorax. 2. No acute trauma in the abdomen or pelvis. [MASKED] CT orbit/sella/IAC w/o contrast: IMPRESSION: 1. Fracture of the occipital bone, longitudinal fractures of the left temporal bone. No fractures of the right temple bone. 2. Opacified left mastoids, middle ear cavity. 3. The known extra-axial hematoma about torcula and venous sinuses are better seen on the same-day CT venogram exam. [MASKED] CT Head venogram: IMPRESSION: 1. Extra-axial hematoma along the posterior margin of the superior sagittal, and medial bilateral transverse sinuses causing moderate to severe narrowing of sinuses, without occlusion few air locule is within the sinus, likely related to left temporal bone fractures. No change in the size of hematoma. Consider venous sinus injury as source of hemorrhage, close imaging follow-up recommended. 2. Stable acute occipital bone, left temporal bone fractures. Brief Hospital Course: Mr. [MASKED] was admitted to the Acute Care Surgery Service under the care of Dr. [MASKED] for further assessment and clinical management of his injuries following his motor vehicle collision. His initial injuries identified during his work up in the Emergency department included a left temporal skull fracture with associated pneumocephalus as well as an exceedingly small right pneumothorax without any associated rib fractures. He was evaluated by the the Neurosurgery Service regarding his skull fracture and pneumocephalus and given that he had no associated neurologic sequelae, it was decided that he did not require any surgical intervention. He underwent additional imaging at the suggestion of the Radiology Department to further characterize intracranial structures not well seen on initial imaging - a CT venogram identified moderately to severely narrowed bilateral transverse sinuses possibly resulting from compression via his extra-cranial hematoma. A Neurology consult was obtained to assess the need for possible anticoagulation as prophylaxis in the setting of stenosis - it was deemed that he did not require any anticoagulation as this imaging finding may have been related to chronic hypoplastic transverse sinuses. It was instead recommended that he undergo repeat imaging and revisit in the Neurology/Stroke Clinic in [MASKED] weeks to assess stability of the narrowing as well as possible progression of any neurologic symptoms. On the evening of HD2, the patient was tolerating a regular diet, voiding and ambulating without difficulty, his pain was well controlled with PO pain medications, his wounds were clean, dry and intact without any evidence of infection, and he remained afebrile, hemodynamically stable, and neurologically intact. He was thus deemed ready for discharge home with follow up in the Acute Care Surgery Clinic in 2 weeks and was instructed to contact the Neuro/Stroke Center to undergo repeat CT venogram and follow up visit. The patient expressed understanding and agreed to the aforementioned plan at the time of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 4000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*0 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Do not drink or drive while taking. Please discard extra. RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp #*10 Tablet Refills:*0 4. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: left temporal bone fracture pneumocephalus possible hypoplastic transverse sinus right pneumothorax 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 [MASKED] for close monitoring following a motor vehicle accident after your Emergency Room imaging confirmed that you sustained a skull fracture and air inside your skull (pneumocephalus), which can be dangerous. You were seen by the Neurosurgery Service who determined that you did not have any injuries that required surgery. You did have additional CAT scans of your head that showed narrowed veings in the brain that were concerning for high risk of blood clot in the brain (venous thrombosis). Neurology determined that you do not need any blood thinners for this, but recommended that you follow up in the Neuro/Stroke Clinic with repeat CAT scan to make sure you're recovering well. Additionally, your imaging showed a very small amount of air in your lung cavity (pneumothorax). This resolved on its own after repeat your chest xray the following day and you did not require any additional interventions. You will be seen in Acute Care Surgery Clinic to make sure you are recovering well from your overall trauma. You are now ready to be discharged home. Please see below for additional 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. *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. Pain control: * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * If your doctor allows, non-steroidal [MASKED] drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. Thank you very much for the opportunity to participate in your care. Best wishes for a speedy recovery! Followup Instructions: [MASKED]
[]
[ "Y929", "F17210" ]
[ "S0219XA: Other fracture of base of skull, initial encounter for closed fracture", "S020XXA: Fracture of vault of skull, initial encounter for closed fracture", "G9389: Other specified disorders of brain", "J939: Pneumothorax, unspecified", "M25562: Pain in left knee", "V475XXA: Car driver injured in collision with fixed or stationary object in traffic accident, initial encounter", "Y929: Unspecified place or not applicable", "F10129: Alcohol abuse with intoxication, unspecified", "R7303: Prediabetes", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,066,209
27,826,282
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Chief Complaint: altered mental status REASON FOR MICU ADMISSION: hypotension Major Surgical or Invasive Procedure: ___: intubation ___: extubation History of Present Illness: Ms. ___ is a ___ with PMH significant for COPD and ischemic stroke with no residual who was transferred from ___ after for further management of hypotension, sepsis and seizures. history per son (not the one present with the patient during the episode): 8pm on ___ the pt needed to use the bedside commode. went once and returned to the bed with assistant of her daughters. She asked to go to the commode again 5 min later. while on the common and the duagheters away, they heard an odd sounds after which they found her unresponsive with her eyes "rolling to the back of her head". they also noted left sided facial drooping and convulsive-like symptoms. no tongue biting, urine incontinent. the daughter did report diarrhea. however, it is not clear whether this represents stool incontinence. They were tapping her cheeks with no response. Minutes later the patient regained her responsiveness and the facial drooping improved. She was noted to be little incoherent and retained a white complexion in her skin. By that time the EMS had arrived. On presentation to ___-M: Temperature: 97.9 F (36.6 C). Pulse: 75. Respiratory Rate: 18. Blood-pressure: 73/52. Oxygen Saturation: 91%. finger stick 173. 135 92 41 ----------< 133 4.6 28 1.6 AG= 15. Ca: 9.1 CT scan did not show evidence of bleeding. There tele-neuro stroke consult did not favor a stroke but rather a seizure. Noted to be hypotensive with SBPs ranging from ___. Was given 4.5L of IVF and a left femoral CVL was inserted in preparation for starting levophed. However her blood pressure improved with fluids. She was given Keppra. On presentation to ED, difficult to obtain history as patient has baseline dementia. Per EMS, unchanged from baseline. Complaining of diffuse abdominal pain. WBC 3 at OSH increased to ___ here. In the ED, initial vitals: 95.02 98 84/56 18 94% RA - Her exam was notable for; Diffuse abdominal tenderness. Mottled ___ - Labs were notable for VBG: pH 7.14 pCO2 72 pO2 45 HCO3 26 Color Yellow Appear Hazy, SpecGr1.022 pH6.5, Urobil 2, Bili Neg, Leuk Lg, Bld Neg, Nitr Neg, Prot 30, Glu Neg, Ket Neg, RBC 4, WBC 30, Bact Few YeastFew Epi 1 Other Urine Counts CastHy: 64 CastCel: 5 Mucous: Rare Lactate:1.9 137 107 35 AGap=15 -------------< 117 4.7 20 1.5 ALT: 25 AP: 178 Tbili: 0.3 Alb: 2.9 AST: 45 LDH: Dbili: TProt: ___: Lip: 54 13.1 MCV 101 21.5 >------< 217 42.5 N:89.3 L:3.3 M:6.3 E:0.2 Bas:0.3 ___: 0.6 Absneut: 19.25 Abslymp: 0.70 Absmono: 1.35 Abseos: 0.04 Absbaso: 0.06 - Imaging showed ___ CT Abd & Pelvis With Contrast 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that left kidney is atrophic. EKG-=NSR @ 88 - Patient was given: -- IV Piperacillin-Tazobactam 4.5 g -- IV Vancomycin 1000 mg -- IV Morphine Sulfate 2 mg -- IV MetRONIDAZOLE (FLagyl) 500 mg -- foley inserted in the ED On arrival to the MICU, the patient is alert and responsive. Her speech is not full coherent. counts the day of the week forward but not backward. is oriented to the type of building. Past Medical History: history of ischemic colitis with admission in ___. history of AF on warfarin which was stopped after she was admitted with GIB on ___ Hypertension Hyperlipidemia Scoliosis DJD hx wrist surgery dyslipidemia chronic neuropathy Arthritis colonosocpy in ___- polyps and villous adenoma on pathology Social History: ___ Family History: none contributory to her current presentation. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: Hr= 111 BP= 85/41 RR=20 O2 sat 81-> 94% on NC GENERAL: sleepy, oriented to place, resting tremor, no acute distress. dry mucus membranes. 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: 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: Mottled ___ . ======================= DISCHARGE PHYSICAL EXAM ======================= VS: 98, 155/86, 98, 20, 95%2L Gen: sitting in bed, comfortable-appearing, less somnolent Eyes - EOMI ENT - OP clear, dry Heart - RRR no mrg Lungs - CTA bilaterally, no wheezes, rales, ronchi Abd - soft, obese, nontender, normoactive bowel sounds Ext - 1+ edema to midshin Skin - large L heel blister; no buttock/sacral wounds Vasc - 1+ DP/radial pulses Neuro - A&Ox2- "hospital" and ___ Psych - pleasant Pertinent Results: ADMISSION LABS: ================= ___ 11:00PM BLOOD WBC-21.5* RBC-4.19 Hgb-13.1 Hct-42.5 MCV-101* MCH-31.3 MCHC-30.8* RDW-15.3 RDWSD-57.8* Plt ___ ___ 11:00PM BLOOD Neuts-89.3* Lymphs-3.3* Monos-6.3 Eos-0.2* Baso-0.3 Im ___ AbsNeut-19.25* AbsLymp-0.70* AbsMono-1.35* AbsEos-0.04 AbsBaso-0.06 ___ 05:22AM BLOOD ___ PTT-27.0 ___ ___ 11:00PM BLOOD Glucose-117* UreaN-35* Creat-1.5* Na-137 K-4.7 Cl-107 HCO3-20* AnGap-15 ___ 11:00PM BLOOD ALT-25 AST-45* AlkPhos-178* TotBili-0.3 ___ 05:22AM BLOOD CK-MB-10 cTropnT-0.09* ___ 05:22AM BLOOD Albumin-3.1* Calcium-7.5* Phos-3.9 Mg-1.6 ___ 01:00AM BLOOD ___ pO2-45* pCO2-72* pH-7.14* calTCO2-26 Base XS--6 ___ 05:30AM BLOOD Lactate-2.2* MICRO: ======= ___ Blood culture negative ___ 11:30 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 ___, ___ @ 02:08AM (___). ___ 1:03 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. ___ 9:40 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: RARE GROWTH Commensal Respiratory Flora. ___ 7:28 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:22 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated IMAGING: ========== Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:46 AM IMPRESSION: Compared to chest radiographs ___ through ___ at 05:24. Lower lung volumes exaggerates the severity of new pulmonary edema. Moderate cardiomegaly is stable but pulmonary vasculature and mediastinal veins are more dilated. Pleural effusion is likely but not large. No pneumothorax. Final Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST IMPRESSION: 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that the left kidney is atrophic. ___ ECHOCARDIOGRAPHY REPORT ___ Conclusions The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad, although a pericardial effusion cannot be excluded with this suboptimal study. No diastolic RV collapse to suggest tamponade. Brief Hospital Course: This is an ___ year old female with past medical history of COPD, prior stroke, admitted with sepsis thought secondary to infectious colitis, course notable for hypoxic respiratory failure requiring intubation, delirium, clinically improved and transferred to the medical floor # Sepsis / Infectious Colitis - patient was admitted with weakness and focal neurologic deficits in the setting of ___, hypotension, hypothermia, leukocytosis and imaging concerning for pan colitis. Given imaging and report of recent diarrhea, patient was felt to have infectious colitis. Additional workup for infection was negative. Patient was treated with broad spectrum antibiotics with subsequent improvement. She will complete 2 weeks cipro/flagyl for infectious colitis. # Metabolic Acidosis / Acute on chronic hypoxic respiratory failure - Patient intermittently on 2L nasal cannula at home, who in the setting of above sepsis and acidosis, was intubated. With treatment of infection she was able to be extubated and remained intermittently between room air and 2L nasal cannula. # Syncope / Initial Neurologic Deficits - per reports, initially had unresponsive episode in setting of diarrhea, with concern for new neurologic deficits; these resolved with treatment of above sepsis; head CT without acute process. Presenting symptoms were suspected to recrudescence of prior stroke in setting of her acute illness and metabolic derrangements. Symptoms did not recur. # Acute metabolic encephalopathy - Patient course complicated by lethargy, felt to be ICU delirium secondary to sedating medications and severe illness above. Improved with delirium precautions, avoiding of sedating medications # Hypertension - continued home lisinopril # Hyperlipidemia - continued ASA, statin # Acute Kidney Injury - Cr 1.6 on presentation, suspected to be hydration. Resolved to 0.6 with IV fluids and treatment of above sepsis # Adv care planning: Lives with ___ and ___. Goal is ultimately for her to go back home with them. ___ is HCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Albuterol Inhaler 2 PUFF IH Q6H 3. Ascorbic Acid ___ mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Acetaminophen 650 mg PO Q4H:PRN pain 6. Lisinopril 20 mg PO DAILY 7. Meclizine 12.5 mg PO TID:PRN dizziness 8. Vitamin E 1000 UNIT PO DAILY 9. Amitriptyline 25 mg PO QHS 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Lisinopril 20 mg PO DAILY 5. Amlodipine 5 mg PO DAILY 6. Ciprofloxacin HCl 500 mg PO Q12H 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. MetroNIDAZOLE 500 mg PO Q8H 9. Albuterol Inhaler 2 PUFF IH Q6H 10. Amitriptyline 25 mg PO QHS 11. Ascorbic Acid ___ mg PO DAILY 12. Gabapentin 600 mg PO TID 13. Meclizine 12.5 mg PO TID:PRN dizziness 14. Vitamin E 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Colitis 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. ___: It was a pleasure caring for you at ___. You were admitted with diarrhea and a low blood pressure. CT scan showed inflammation in your intestines concerning for an infection. You were treated with fluids and antibiotics. You improved and are now ready for discharge. You are being discharged to Marina Bay, for additional physical therapy. Followup Instructions: ___
[ "A419", "R6521", "J9621", "I214", "G9341", "G629", "N179", "E874", "I4891", "M419", "A09", "I248", "Z66", "J449", "Z8673", "I10", "E785", "M1990", "Z86010", "Z720", "R55", "Z7982", "L89622", "F0390" ]
Allergies: oxycodone Chief Complaint: altered mental status REASON FOR MICU ADMISSION: hypotension Major Surgical or Invasive Procedure: [MASKED]: intubation [MASKED]: extubation History of Present Illness: Ms. [MASKED] is a [MASKED] with PMH significant for COPD and ischemic stroke with no residual who was transferred from [MASKED] after for further management of hypotension, sepsis and seizures. history per son (not the one present with the patient during the episode): 8pm on [MASKED] the pt needed to use the bedside commode. went once and returned to the bed with assistant of her daughters. She asked to go to the commode again 5 min later. while on the common and the duagheters away, they heard an odd sounds after which they found her unresponsive with her eyes "rolling to the back of her head". they also noted left sided facial drooping and convulsive-like symptoms. no tongue biting, urine incontinent. the daughter did report diarrhea. however, it is not clear whether this represents stool incontinence. They were tapping her cheeks with no response. Minutes later the patient regained her responsiveness and the facial drooping improved. She was noted to be little incoherent and retained a white complexion in her skin. By that time the EMS had arrived. On presentation to [MASKED]-M: Temperature: 97.9 F (36.6 C). Pulse: 75. Respiratory Rate: 18. Blood-pressure: 73/52. Oxygen Saturation: 91%. finger stick 173. 135 92 41 ----------< 133 4.6 28 1.6 AG= 15. Ca: 9.1 CT scan did not show evidence of bleeding. There tele-neuro stroke consult did not favor a stroke but rather a seizure. Noted to be hypotensive with SBPs ranging from [MASKED]. Was given 4.5L of IVF and a left femoral CVL was inserted in preparation for starting levophed. However her blood pressure improved with fluids. She was given Keppra. On presentation to ED, difficult to obtain history as patient has baseline dementia. Per EMS, unchanged from baseline. Complaining of diffuse abdominal pain. WBC 3 at OSH increased to [MASKED] here. In the ED, initial vitals: 95.02 98 84/56 18 94% RA - Her exam was notable for; Diffuse abdominal tenderness. Mottled [MASKED] - Labs were notable for VBG: pH 7.14 pCO2 72 pO2 45 HCO3 26 Color Yellow Appear Hazy, SpecGr1.022 pH6.5, Urobil 2, Bili Neg, Leuk Lg, Bld Neg, Nitr Neg, Prot 30, Glu Neg, Ket Neg, RBC 4, WBC 30, Bact Few YeastFew Epi 1 Other Urine Counts CastHy: 64 CastCel: 5 Mucous: Rare Lactate:1.9 137 107 35 AGap=15 -------------< 117 4.7 20 1.5 ALT: 25 AP: 178 Tbili: 0.3 Alb: 2.9 AST: 45 LDH: Dbili: TProt: [MASKED]: Lip: 54 13.1 MCV 101 21.5 >------< 217 42.5 N:89.3 L:3.3 M:6.3 E:0.2 Bas:0.3 [MASKED]: 0.6 Absneut: 19.25 Abslymp: 0.70 Absmono: 1.35 Abseos: 0.04 Absbaso: 0.06 - Imaging showed [MASKED] CT Abd & Pelvis With Contrast 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that left kidney is atrophic. EKG-=NSR @ 88 - Patient was given: -- IV Piperacillin-Tazobactam 4.5 g -- IV Vancomycin 1000 mg -- IV Morphine Sulfate 2 mg -- IV MetRONIDAZOLE (FLagyl) 500 mg -- foley inserted in the ED On arrival to the MICU, the patient is alert and responsive. Her speech is not full coherent. counts the day of the week forward but not backward. is oriented to the type of building. Past Medical History: history of ischemic colitis with admission in [MASKED]. history of AF on warfarin which was stopped after she was admitted with GIB on [MASKED] Hypertension Hyperlipidemia Scoliosis DJD hx wrist surgery dyslipidemia chronic neuropathy Arthritis colonosocpy in [MASKED]- polyps and villous adenoma on pathology Social History: [MASKED] Family History: none contributory to her current presentation. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: Hr= 111 BP= 85/41 RR=20 O2 sat 81-> 94% on NC GENERAL: sleepy, oriented to place, resting tremor, no acute distress. dry mucus membranes. 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: 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: Mottled [MASKED] . ======================= DISCHARGE PHYSICAL EXAM ======================= VS: 98, 155/86, 98, 20, 95%2L Gen: sitting in bed, comfortable-appearing, less somnolent Eyes - EOMI ENT - OP clear, dry Heart - RRR no mrg Lungs - CTA bilaterally, no wheezes, rales, ronchi Abd - soft, obese, nontender, normoactive bowel sounds Ext - 1+ edema to midshin Skin - large L heel blister; no buttock/sacral wounds Vasc - 1+ DP/radial pulses Neuro - A&Ox2- "hospital" and [MASKED] Psych - pleasant Pertinent Results: ADMISSION LABS: ================= [MASKED] 11:00PM BLOOD WBC-21.5* RBC-4.19 Hgb-13.1 Hct-42.5 MCV-101* MCH-31.3 MCHC-30.8* RDW-15.3 RDWSD-57.8* Plt [MASKED] [MASKED] 11:00PM BLOOD Neuts-89.3* Lymphs-3.3* Monos-6.3 Eos-0.2* Baso-0.3 Im [MASKED] AbsNeut-19.25* AbsLymp-0.70* AbsMono-1.35* AbsEos-0.04 AbsBaso-0.06 [MASKED] 05:22AM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 11:00PM BLOOD Glucose-117* UreaN-35* Creat-1.5* Na-137 K-4.7 Cl-107 HCO3-20* AnGap-15 [MASKED] 11:00PM BLOOD ALT-25 AST-45* AlkPhos-178* TotBili-0.3 [MASKED] 05:22AM BLOOD CK-MB-10 cTropnT-0.09* [MASKED] 05:22AM BLOOD Albumin-3.1* Calcium-7.5* Phos-3.9 Mg-1.6 [MASKED] 01:00AM BLOOD [MASKED] pO2-45* pCO2-72* pH-7.14* calTCO2-26 Base XS--6 [MASKED] 05:30AM BLOOD Lactate-2.2* MICRO: ======= [MASKED] Blood culture negative [MASKED] 11:30 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] @ 02:08AM ([MASKED]). [MASKED] 1:03 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: NO GROWTH, <1000 CFU/ml. [MASKED] 9:40 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [MASKED]: RARE GROWTH Commensal Respiratory Flora. [MASKED] 7:28 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:22 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated IMAGING: ========== Radiology Report CHEST (PORTABLE AP) Study Date of [MASKED] 4:46 AM IMPRESSION: Compared to chest radiographs [MASKED] through [MASKED] at 05:24. Lower lung volumes exaggerates the severity of new pulmonary edema. Moderate cardiomegaly is stable but pulmonary vasculature and mediastinal veins are more dilated. Pleural effusion is likely but not large. No pneumothorax. Final Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST IMPRESSION: 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that the left kidney is atrophic. [MASKED] ECHOCARDIOGRAPHY REPORT [MASKED] Conclusions The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad, although a pericardial effusion cannot be excluded with this suboptimal study. No diastolic RV collapse to suggest tamponade. Brief Hospital Course: This is an [MASKED] year old female with past medical history of COPD, prior stroke, admitted with sepsis thought secondary to infectious colitis, course notable for hypoxic respiratory failure requiring intubation, delirium, clinically improved and transferred to the medical floor # Sepsis / Infectious Colitis - patient was admitted with weakness and focal neurologic deficits in the setting of [MASKED], hypotension, hypothermia, leukocytosis and imaging concerning for pan colitis. Given imaging and report of recent diarrhea, patient was felt to have infectious colitis. Additional workup for infection was negative. Patient was treated with broad spectrum antibiotics with subsequent improvement. She will complete 2 weeks cipro/flagyl for infectious colitis. # Metabolic Acidosis / Acute on chronic hypoxic respiratory failure - Patient intermittently on 2L nasal cannula at home, who in the setting of above sepsis and acidosis, was intubated. With treatment of infection she was able to be extubated and remained intermittently between room air and 2L nasal cannula. # Syncope / Initial Neurologic Deficits - per reports, initially had unresponsive episode in setting of diarrhea, with concern for new neurologic deficits; these resolved with treatment of above sepsis; head CT without acute process. Presenting symptoms were suspected to recrudescence of prior stroke in setting of her acute illness and metabolic derrangements. Symptoms did not recur. # Acute metabolic encephalopathy - Patient course complicated by lethargy, felt to be ICU delirium secondary to sedating medications and severe illness above. Improved with delirium precautions, avoiding of sedating medications # Hypertension - continued home lisinopril # Hyperlipidemia - continued ASA, statin # Acute Kidney Injury - Cr 1.6 on presentation, suspected to be hydration. Resolved to 0.6 with IV fluids and treatment of above sepsis # Adv care planning: Lives with [MASKED] and [MASKED]. Goal is ultimately for her to go back home with them. [MASKED] is HCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Albuterol Inhaler 2 PUFF IH Q6H 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Acetaminophen 650 mg PO Q4H:PRN pain 6. Lisinopril 20 mg PO DAILY 7. Meclizine 12.5 mg PO TID:PRN dizziness 8. Vitamin E 1000 UNIT PO DAILY 9. Amitriptyline 25 mg PO QHS 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Lisinopril 20 mg PO DAILY 5. Amlodipine 5 mg PO DAILY 6. Ciprofloxacin HCl 500 mg PO Q12H 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. MetroNIDAZOLE 500 mg PO Q8H 9. Albuterol Inhaler 2 PUFF IH Q6H 10. Amitriptyline 25 mg PO QHS 11. Ascorbic Acid [MASKED] mg PO DAILY 12. Gabapentin 600 mg PO TID 13. Meclizine 12.5 mg PO TID:PRN dizziness 14. Vitamin E 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Colitis 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]: It was a pleasure caring for you at [MASKED]. You were admitted with diarrhea and a low blood pressure. CT scan showed inflammation in your intestines concerning for an infection. You were treated with fluids and antibiotics. You improved and are now ready for discharge. You are being discharged to Marina Bay, for additional physical therapy. Followup Instructions: [MASKED]
[]
[ "N179", "I4891", "Z66", "J449", "Z8673", "I10", "E785" ]
[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "J9621: Acute and chronic respiratory failure with hypoxia", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "G9341: Metabolic encephalopathy", "G629: Polyneuropathy, unspecified", "N179: Acute kidney failure, unspecified", "E874: Mixed disorder of acid-base balance", "I4891: Unspecified atrial fibrillation", "M419: Scoliosis, unspecified", "A09: Infectious gastroenteritis and colitis, unspecified", "I248: Other forms of acute ischemic heart disease", "Z66: Do not resuscitate", "J449: Chronic obstructive pulmonary disease, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z86010: Personal history of colonic polyps", "Z720: Tobacco use", "R55: Syncope and collapse", "Z7982: Long term (current) use of aspirin", "L89622: Pressure ulcer of left heel, stage 2", "F0390: Unspecified dementia without behavioral disturbance" ]
10,066,415
29,335,147
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Progressive AMS Major Surgical or Invasive Procedure: lumbar puncture x2 History of Present Illness: ___ with hx of remote MI, IDDM2, gastritis/H. pylori, colonic AVM, reported recent diagnosis of ?giant cell arteritis, presenting with AMS. History is obtained from pt's son, ___, by telephone. Son, ___, who lives with the patient, reports that pt developed severe headaches in late ___, for which he was evaluated at ___. On ___, a head CT at ___ apparently revealed a history of stroke. F/u MRI on ___ reportedly revealed 2 prior CVAs in unknown distribution, "ministrokes." On ___, he was evaluated by a neurologist, who apparently diagnosed him with giant cell arteritis. He was prescribed prednisone 50 mg daily. In early ___, his family noted physical and cognitive deterioration. Bad headaches persisted. With respect to his cognitive functioning, he had days with a lot of confusion, did not recognize family members, visual hallucinations (people). At one point his mobility was minimal, ambulating just to the bathroom or to the kitchen for meals. His family made the decision to transition his care from ___ to ___ given his progressive symptoms. ___ notes that pt's cognitive status on day of admission is actually somewhat better compared to many other days. Pt was agreeable to evaluation at ___. Prednisone dose is now down to 20 mg daily. ___ reports that a biopsy was done of the R temporal artery, the results of which were reportedly negative. Pt has never reported chest pain, SOB, diarrhea at home. He has had issues with constipation in the past, which his family attributes to iron pills. He has never mentioned dysuria to his family, but they have noticed frequent urination. Blood sugars at home were elevated, checked in the am before breakfast. ___ reports blood sugars: ___ 355, then peaked on ___ at 511, with the lowest number on the following day, ___ at 117. ___ reports that the pt has not fallen at home. In the ___ ED: VS 98.2, 85, 133/62, 100% RA Labs notable for WBC 14.6, Hb 11.9, Na 131, Cr 1.1, lactate 1.7 UA positive CXR and head CT unrevealing Received ceftriaxone 1 gm IV x1, 500 cc IVF, and insulin 8u sc On arrival to the floor, pt endorses ___ R sided headache, which he has difficulty further characterizing. He denies chest pain, abdominal pain, dysuria, hematuria, diarrhea, constipation, SOB. ROS: limited by AMS Past Medical History: Per OMR, unable to confirm with pt ___ AMS, reviewed with family: # h/o MI at age ___ s/p cardiac arrest, "treated with medication for a few years then weaned off", no intervention. Reportedly has had 3 total MIs, most recently in the late ___, no stents. S/p CABG x4v ___. # DM2 # Hypertriglyceridemia # Gastritis/H. pylori (on previous EGD reports) # R ___ nerve palsy # H/I GI bleeding - ? duodentitis PSH s/p ___ inguinal hernia repair Social History: ___ Family History: Per OMR: No FH any bleeding d/o, malignancy. Father died of MI in early ___ Physical Exam: VS 97.7 PO 161 / 71 108 18 100 RA Gen: pleasant, elderly male, NAD HEENT: PERRL, EOMI, clear oropharynx, poor dentition, MMM, anicteric sclera Neck: supple, no cervical or supraclavicular adenopathy, no carotid bruit CV: RRR, ___ systolic murmur at ___, no rubs or gallops Lungs: CTAB, no wheeze or rhonchi Abd: soft, nontender, nondistended, no rebound or guarding, +BS, no suprapubic TTP GU: No foley Ext: WWP, no c/c/e Neuro: alert and oriented to person only. Knows that he is in a hospital, unable to name the hospital, when informed that it is ___, he acknowledges that he thought he was in ___. States that it is "66" for the year, and "26 or 27" for the month. Intermittently follows commands. CN II-XII intact, strength ___ in UE and ___ bilaterally. Discharge Exam: 97.4 PO 142 / 63 91 18 100 Gen: alert, awake, obese, answers simple questions HEENT: OP clear, MMM, makes good eye contact Lungs CTAB no w/r/r Cardiac: RRR, S1, S2 Neuro: alert, confused, consistent with prior exams, follow simple questions GU: foley in place, otherwise deferred Abd: nontender, soft, BS+, nondistended, no rebound or guarding Ext: warm, dry, no edema Psych: restricted Pertinent Results: ___ 01:42PM URINE HOURS-RANDOM ___ 01:42PM URINE HOURS-RANDOM ___ 01:42PM URINE UHOLD-HOLD ___ 01:42PM URINE GR HOLD-HOLD ___ 01:42PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 01:42PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 01:11PM LACTATE-1.7 ___ 01:04PM GLUCOSE-295* UREA N-16 CREAT-1.1 SODIUM-131* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-22 ANION GAP-19 ___ 01:04PM estGFR-Using this ___ 01:04PM cTropnT-<0.01 ___ 01:04PM WBC-14.6*# RBC-3.93* HGB-11.9* HCT-35.3* MCV-90# MCH-30.3# MCHC-33.7 RDW-14.6 RDWSD-46.5* ___ 01:04PM NEUTS-94* BANDS-1 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ___ MYELOS-2* AbsNeut-13.87* AbsLymp-0.29* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00* ___ 01:04PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+ TEARDROP-1+ ___ 01:04PM PLT SMR-NORMAL PLT COUNT-177# CSF studies: ============ Protein 289 Glucose 133 8 WBCs, 41 Reds Atypical cells seen Final Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ man with altered mental status, evaluate for intracranial process. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 1,104 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are enlarged for the patient's age suggesting cerebral atrophy. Periventricular white matter hypodensities are nonspecific but likely reflect sequela of chronic small vessel disease. Dense atherosclerotic calcifications of the cavernous carotid arteries are noted along with mild atherosclerotic calcifications of the right distal vertebral artery. There is no evidence of fracture. The visualized portion of the paranasal sinuses, and middle ear cavities are clear. There is a small amount of fluid in the right mastoid air cells. The visualized portion of the orbits are unremarkable. There are calcifications of the bilateral cavernous carotid arteries. IMPRESSION: No acute intracranial process. Final Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with Altered mental Status TECHNIQUE: Supine AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Patient is status post median sternotomy, CABG, and coronary artery stenting. Mild cardiomegaly is re- demonstrated. Atherosclerotic calcifications are noted at the aortic knob. The mediastinal and hilar contours are otherwise unremarkable. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion or pneumothorax is demonstrated. No acute osseous abnormality is visualized. IMPRESSION: No acute cardiopulmonary abnormality. ___ RI head IMPRESSION: No acute infarcts. Moderate changes of small vessel disease and brain atrophy. 5 mm left frontal meningioma without mass effect on the brain. No other areas of abnormal enhancement. CYTOLOGY POSITIVE FOR MALIGNANT CELLS. - Metastatic lung adenocarcinoma. - Immunohistochemical stains show the tumor cells to express both TTF-1 and Napsin-A. Note: The prepared cell block has scant tumor cellularity. IMPRESSION: 1. 3.4 x 2.5 x 3.2 cm mass in the superior segment of the left lower lobe, concerning for a primary lung neoplasm. If clinically indicated, this would likely be amenable to bronchoscopic approach for tissue sampling. Additionally, PET-CT could be considered. 2. Dense consolidation in the right upper lobe spans approximately 3.2 cm with adjacent ground-glass opacity and mild parenchymal architectural distortion. While this could be infectious/ inflammatory in etiology, additional neoplastic involvement is considered. 3. Please refer to the dedicated CT abdomen pelvis report of the same date for the subdiaphragmatic findings. NOTIFICATION: The above findings and recommendation were communicated via telephone by Dr. ___ to Dr. ___ at 21:03 on ___, 2 min after discovery. 1. 1.9 cm left adrenal nodule, which is incompletely characterized on the current CT. Given the concurrent chest CT findings of a suspected primary lung neoplasm, this is concerning for a metastatic lesion. 2. No evidence of retroperitoneal, mesenteric, pelvic, or inguinal lymphadenopathy. 3. Severe atherosclerotic calcifications involving the abdominal aorta, renal artery origins, and bilateral iliac arteries. 4. Please refer to the dedicated CT chest report of the same date for the intrathoracic findings. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 21:03 on ___, 2 min after discovery. ___ 01:15PM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-Test Name ___ 07:30AM BLOOD ALT-13 AST-12 AlkPhos-53 TotBili-0.3 ___ 01:04PM BLOOD cTropnT-<0.01 ___ 05:02PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-39* Polys-1 ___ Macroph-1 ___ 05:02PM CEREBROSPINAL FLUID (CSF) TotProt-230* Glucose-100 LD(LDH)-58 Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Paraneoplastic Autoantib Eval, CSF Anti-Neuronal Nuclear Ab, Type 1 ___, CSF Negative Titer Negative at <1:2 Reflex Added ___. Anti-Neuronal Nuclear Ab, Type 2 ___, CSF Negative Titer Negative at <1:2 Anti-Neuronal Nuclear Ab, Type 3 ___, CSF Negative Titer Negative at <1:2 Anti-Glial Nuclear Ab, Type 1 AGNA-1, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type 1 PCA-1, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type 2 PCA-2, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type Tr PCA-Tr, CSF Negative Titer Negative at <1:2 Amphiphysin Ab, CSF Negative Titer Negative at <1:2 CRMP-5-IgG, CSF Negative Titer ___ CT abd/pelvis non-contrast: FINDINGS: LOWER CHEST: Small bilateral pleural effusions are present, there is right basilar atelectasis, with possibly small consolidation, new since the prior examination. . ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains a large calcified stone, without pericholecystic fat stranding, wall edema, or gallbladder distention. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. Again seen is a small accessory spleen. ADRENALS: The year right adrenal gland is normal. A left adrenal gland nodule is again seen, measuring 1.9 cm, unchanged since the prior examination. URINARY: The kidneys are of normal and symmetric size. A hypodense lesion is again seen in the interpolar region of the left kidney, likely a cyst. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: Again seen is a moderate hiatal hernia. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is diverticulosis. Though the appendix is not definitively visualized, there are no secondary signs of appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. Status post bilateral inguinal hernia repair with Prolene plug. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Marked atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Presumed bone islands are identified in the left iliac bone. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is no evidence of retroperitoneal hematoma. IMPRESSION: 1. No evidence of retroperitoneal hematoma. Discharge Labs: ___ 07:00AM BLOOD WBC-12.7* RBC-2.74* Hgb-8.5* Hct-24.6* MCV-90 MCH-31.0 MCHC-34.6 RDW-16.7* RDWSD-52.6* Plt ___ ___ 06:35AM BLOOD ___ ___ 07:00AM BLOOD Glucose-73 UreaN-20 Creat-0.9 Na-132* K-3.9 Cl-96 HCO3-24 AnGap-16 ___ 07:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 ___ 08:10AM BLOOD %HbA1c-10.3* eAG-249* Brief Hospital Course: ___ with giant cell arteritis on prednisone presenting with rapidly progressive encephalopathy found to have metastatic lung adenocarcinoma s/p biopsy of adrenal mass with mets to leptomeninges, course complicated by anemia and tachycardia attributed to upper GI blood loss, now improved. Given poor prognosis, discharging with hospice. # Progressive Encephalopathy secondary to leptomeningeal involvement spread of malignancy: Significant concern for leptomeningeal carcinomatosis given elevated CSF opening pressure, elevated protein >200 and cell count, CSF cytology positive for malignant cells. Infectious workup negative, no seizures on EEG, no masses on imaging. Neuro-onc, heme-onc consulted and recommended dexamethasone for symptom based treatment, no other options available, poor prognosis. Started on dexamethasone 4mg BID with symptomatic improvement in mental status. Given hyperglycemic, evidence of blood loss, decreased dexamethasone to 2mg BID, mental status remained stable. Discussed with family that this can be further adjusted given that this is symptomatic treatment alone, however wished to keep current dose. - dexamethasone 2mg PO BID - pantoprazole 40mg PO BID # Metastatis lung adenocarcinoma: Former smoker, 20 pack year history. LLL mass, adrenal met and leptomeningeal spread. Heme-onc, neuro-onc consulted, unfortunately poor prognosis without treatment options. - DNR/DNI/no MICU transfer - MOLST signed ___ with alternate HCP son in discussion by phone with wife - no active symptom management at this time, not eligible for GIP hospice - planned discharge with hospice - Tylenol ___ PO TID, not requiring additional pain control # Anemia with acute blood loss with tachycardia: Resolved. Guaiac positive stool, on high dose steroids, no frank GI bleed or pulmonary symptoms, and no RP bleed on CT abd/pelvis, so suspect upper GI source. S/p 2u PRBCs with improvement in CBC, tachycardia. Increased PPI to BID, CBC stabilized and no longer checking given clinical stability and goals of care. - PPI BID - steroids at 2mg BID, can consider decrease to daily in the future - prn Maalox, Carafate for indigestion (not requiring) - discontinued aspirin given GI bleed # DMII/Hyperglycemia: With high dose steroids elevated FSBG requiring uptitration of lantus and Humalog, A1c >10, so likely hyperglycemic prior to admission as well and was on steroids prior to admission. Upon discharge, dexamethasone near pre-admission pred equivalent (26mg, was taking 20mg). With dexamethasone decrease, insulin downtitrated, transition back to PO glipizide upon discharge for ease of administration. - glipizide 5mg PO BID - daily FSBG monitoring be pursued but is not necessary given goals of care (FSBG <150 - hold glipizide; >400 10mg BID glipizide, otherwise maintain dose) - if not tolerating PO, please do not give glipizide # EKG abnormalities: Suspicion for prior MI, probably silent in setting of uncontrolled DMII, started on low dose metop 6.25mg BID, transitioned to 12.5mg XL upon discharge. # History of urinary retention s/p foley placement: Discussed with family. Prefer to leave foley in place for comfort, avoiding straight cath. Discussed that this can be revisited at any time and that he is at risk for infection with indwelling catheter. #Contact: Wife ___, ___ son ___ ___ ___ stable for discharge home with hospice. > 30 minutes spent on discharge day services, counseling, and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 20 mg PO DAILY 2. GlipiZIDE 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO Frequency is Unknown 6. Vitamin D Dose is Unknown PO DAILY 7. Cyanocobalamin Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN gas pain, indigestion 3. Dexamethasone 2 mg PO Q12H RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Metoprolol Succinate XL 12.5 mg PO DAILY RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation 9. GlipiZIDE 5 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Metastatic lung adenocarcinoma with adrenal metastasis and suspected Leptomeningeal carcinomatosis 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 admitted to the hospital with worsening confusion and were unfortunately found to have metastatic lung cancer, which has spread to the brain. You were started on steroids, which helped your symptoms. You were seen by the Neuro-oncologists and Medical Oncologists, and unfortunately there are no good treatment options, and with your family, the you are being transferred home for further care. We wish you the best. Followup Instructions: ___
[ "C3432", "G9349", "C7932", "C7972", "H4921", "E1165", "D62", "E871", "I252", "Z66", "Z794", "Z8673", "Z8674", "E781", "Z951", "Z87891", "R195", "R339", "I4510", "K5520", "K219", "R51", "D509", "E785" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Progressive AMS Major Surgical or Invasive Procedure: lumbar puncture x2 History of Present Illness: [MASKED] with hx of remote MI, IDDM2, gastritis/H. pylori, colonic AVM, reported recent diagnosis of ?giant cell arteritis, presenting with AMS. History is obtained from pt's son, [MASKED], by telephone. Son, [MASKED], who lives with the patient, reports that pt developed severe headaches in late [MASKED], for which he was evaluated at [MASKED]. On [MASKED], a head CT at [MASKED] apparently revealed a history of stroke. F/u MRI on [MASKED] reportedly revealed 2 prior CVAs in unknown distribution, "ministrokes." On [MASKED], he was evaluated by a neurologist, who apparently diagnosed him with giant cell arteritis. He was prescribed prednisone 50 mg daily. In early [MASKED], his family noted physical and cognitive deterioration. Bad headaches persisted. With respect to his cognitive functioning, he had days with a lot of confusion, did not recognize family members, visual hallucinations (people). At one point his mobility was minimal, ambulating just to the bathroom or to the kitchen for meals. His family made the decision to transition his care from [MASKED] to [MASKED] given his progressive symptoms. [MASKED] notes that pt's cognitive status on day of admission is actually somewhat better compared to many other days. Pt was agreeable to evaluation at [MASKED]. Prednisone dose is now down to 20 mg daily. [MASKED] reports that a biopsy was done of the R temporal artery, the results of which were reportedly negative. Pt has never reported chest pain, SOB, diarrhea at home. He has had issues with constipation in the past, which his family attributes to iron pills. He has never mentioned dysuria to his family, but they have noticed frequent urination. Blood sugars at home were elevated, checked in the am before breakfast. [MASKED] reports blood sugars: [MASKED] 355, then peaked on [MASKED] at 511, with the lowest number on the following day, [MASKED] at 117. [MASKED] reports that the pt has not fallen at home. In the [MASKED] ED: VS 98.2, 85, 133/62, 100% RA Labs notable for WBC 14.6, Hb 11.9, Na 131, Cr 1.1, lactate 1.7 UA positive CXR and head CT unrevealing Received ceftriaxone 1 gm IV x1, 500 cc IVF, and insulin 8u sc On arrival to the floor, pt endorses [MASKED] R sided headache, which he has difficulty further characterizing. He denies chest pain, abdominal pain, dysuria, hematuria, diarrhea, constipation, SOB. ROS: limited by AMS Past Medical History: Per OMR, unable to confirm with pt [MASKED] AMS, reviewed with family: # h/o MI at age [MASKED] s/p cardiac arrest, "treated with medication for a few years then weaned off", no intervention. Reportedly has had 3 total MIs, most recently in the late [MASKED], no stents. S/p CABG x4v [MASKED]. # DM2 # Hypertriglyceridemia # Gastritis/H. pylori (on previous EGD reports) # R [MASKED] nerve palsy # H/I GI bleeding - ? duodentitis PSH s/p [MASKED] inguinal hernia repair Social History: [MASKED] Family History: Per OMR: No FH any bleeding d/o, malignancy. Father died of MI in early [MASKED] Physical Exam: VS 97.7 PO 161 / 71 108 18 100 RA Gen: pleasant, elderly male, NAD HEENT: PERRL, EOMI, clear oropharynx, poor dentition, MMM, anicteric sclera Neck: supple, no cervical or supraclavicular adenopathy, no carotid bruit CV: RRR, [MASKED] systolic murmur at [MASKED], no rubs or gallops Lungs: CTAB, no wheeze or rhonchi Abd: soft, nontender, nondistended, no rebound or guarding, +BS, no suprapubic TTP GU: No foley Ext: WWP, no c/c/e Neuro: alert and oriented to person only. Knows that he is in a hospital, unable to name the hospital, when informed that it is [MASKED], he acknowledges that he thought he was in [MASKED]. States that it is "66" for the year, and "26 or 27" for the month. Intermittently follows commands. CN II-XII intact, strength [MASKED] in UE and [MASKED] bilaterally. Discharge Exam: 97.4 PO 142 / 63 91 18 100 Gen: alert, awake, obese, answers simple questions HEENT: OP clear, MMM, makes good eye contact Lungs CTAB no w/r/r Cardiac: RRR, S1, S2 Neuro: alert, confused, consistent with prior exams, follow simple questions GU: foley in place, otherwise deferred Abd: nontender, soft, BS+, nondistended, no rebound or guarding Ext: warm, dry, no edema Psych: restricted Pertinent Results: [MASKED] 01:42PM URINE HOURS-RANDOM [MASKED] 01:42PM URINE HOURS-RANDOM [MASKED] 01:42PM URINE UHOLD-HOLD [MASKED] 01:42PM URINE GR HOLD-HOLD [MASKED] 01:42PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 01:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [MASKED] 01:42PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [MASKED] 01:11PM LACTATE-1.7 [MASKED] 01:04PM GLUCOSE-295* UREA N-16 CREAT-1.1 SODIUM-131* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-22 ANION GAP-19 [MASKED] 01:04PM estGFR-Using this [MASKED] 01:04PM cTropnT-<0.01 [MASKED] 01:04PM WBC-14.6*# RBC-3.93* HGB-11.9* HCT-35.3* MCV-90# MCH-30.3# MCHC-33.7 RDW-14.6 RDWSD-46.5* [MASKED] 01:04PM NEUTS-94* BANDS-1 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 [MASKED] MYELOS-2* AbsNeut-13.87* AbsLymp-0.29* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:04PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+ TEARDROP-1+ [MASKED] 01:04PM PLT SMR-NORMAL PLT COUNT-177# CSF studies: ============ Protein 289 Glucose 133 8 WBCs, 41 Reds Atypical cells seen Final Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: [MASKED] man with altered mental status, evaluate for intracranial process. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 1,104 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are enlarged for the patient's age suggesting cerebral atrophy. Periventricular white matter hypodensities are nonspecific but likely reflect sequela of chronic small vessel disease. Dense atherosclerotic calcifications of the cavernous carotid arteries are noted along with mild atherosclerotic calcifications of the right distal vertebral artery. There is no evidence of fracture. The visualized portion of the paranasal sinuses, and middle ear cavities are clear. There is a small amount of fluid in the right mastoid air cells. The visualized portion of the orbits are unremarkable. There are calcifications of the bilateral cavernous carotid arteries. IMPRESSION: No acute intracranial process. Final Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: [MASKED] with Altered mental Status TECHNIQUE: Supine AP and lateral views of the chest COMPARISON: Chest radiograph [MASKED] FINDINGS: Patient is status post median sternotomy, CABG, and coronary artery stenting. Mild cardiomegaly is re- demonstrated. Atherosclerotic calcifications are noted at the aortic knob. The mediastinal and hilar contours are otherwise unremarkable. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion or pneumothorax is demonstrated. No acute osseous abnormality is visualized. IMPRESSION: No acute cardiopulmonary abnormality. [MASKED] RI head IMPRESSION: No acute infarcts. Moderate changes of small vessel disease and brain atrophy. 5 mm left frontal meningioma without mass effect on the brain. No other areas of abnormal enhancement. CYTOLOGY POSITIVE FOR MALIGNANT CELLS. - Metastatic lung adenocarcinoma. - Immunohistochemical stains show the tumor cells to express both TTF-1 and Napsin-A. Note: The prepared cell block has scant tumor cellularity. IMPRESSION: 1. 3.4 x 2.5 x 3.2 cm mass in the superior segment of the left lower lobe, concerning for a primary lung neoplasm. If clinically indicated, this would likely be amenable to bronchoscopic approach for tissue sampling. Additionally, PET-CT could be considered. 2. Dense consolidation in the right upper lobe spans approximately 3.2 cm with adjacent ground-glass opacity and mild parenchymal architectural distortion. While this could be infectious/ inflammatory in etiology, additional neoplastic involvement is considered. 3. Please refer to the dedicated CT abdomen pelvis report of the same date for the subdiaphragmatic findings. NOTIFICATION: The above findings and recommendation were communicated via telephone by Dr. [MASKED] to Dr. [MASKED] at 21:03 on [MASKED], 2 min after discovery. 1. 1.9 cm left adrenal nodule, which is incompletely characterized on the current CT. Given the concurrent chest CT findings of a suspected primary lung neoplasm, this is concerning for a metastatic lesion. 2. No evidence of retroperitoneal, mesenteric, pelvic, or inguinal lymphadenopathy. 3. Severe atherosclerotic calcifications involving the abdominal aorta, renal artery origins, and bilateral iliac arteries. 4. Please refer to the dedicated CT chest report of the same date for the intrathoracic findings. NOTIFICATION: The above findings were communicated via telephone by Dr. [MASKED] to Dr. [MASKED] at 21:03 on [MASKED], 2 min after discovery. [MASKED] 01:15PM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-Test Name [MASKED] 07:30AM BLOOD ALT-13 AST-12 AlkPhos-53 TotBili-0.3 [MASKED] 01:04PM BLOOD cTropnT-<0.01 [MASKED] 05:02PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-39* Polys-1 [MASKED] Macroph-1 [MASKED] 05:02PM CEREBROSPINAL FLUID (CSF) TotProt-230* Glucose-100 LD(LDH)-58 Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Paraneoplastic Autoantib Eval, CSF Anti-Neuronal Nuclear Ab, Type 1 [MASKED], CSF Negative Titer Negative at <1:2 Reflex Added [MASKED]. Anti-Neuronal Nuclear Ab, Type 2 [MASKED], CSF Negative Titer Negative at <1:2 Anti-Neuronal Nuclear Ab, Type 3 [MASKED], CSF Negative Titer Negative at <1:2 Anti-Glial Nuclear Ab, Type 1 AGNA-1, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type 1 PCA-1, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type 2 PCA-2, CSF Negative Titer Negative at <1:2 Purkinje Cell Cytoplasmic Ab Type Tr PCA-Tr, CSF Negative Titer Negative at <1:2 Amphiphysin Ab, CSF Negative Titer Negative at <1:2 CRMP-5-IgG, CSF Negative Titer [MASKED] CT abd/pelvis non-contrast: FINDINGS: LOWER CHEST: Small bilateral pleural effusions are present, there is right basilar atelectasis, with possibly small consolidation, new since the prior examination. . ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains a large calcified stone, without pericholecystic fat stranding, wall edema, or gallbladder distention. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. Again seen is a small accessory spleen. ADRENALS: The year right adrenal gland is normal. A left adrenal gland nodule is again seen, measuring 1.9 cm, unchanged since the prior examination. URINARY: The kidneys are of normal and symmetric size. A hypodense lesion is again seen in the interpolar region of the left kidney, likely a cyst. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: Again seen is a moderate hiatal hernia. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is diverticulosis. Though the appendix is not definitively visualized, there are no secondary signs of appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. Status post bilateral inguinal hernia repair with Prolene plug. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Marked atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Presumed bone islands are identified in the left iliac bone. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is no evidence of retroperitoneal hematoma. IMPRESSION: 1. No evidence of retroperitoneal hematoma. Discharge Labs: [MASKED] 07:00AM BLOOD WBC-12.7* RBC-2.74* Hgb-8.5* Hct-24.6* MCV-90 MCH-31.0 MCHC-34.6 RDW-16.7* RDWSD-52.6* Plt [MASKED] [MASKED] 06:35AM BLOOD [MASKED] [MASKED] 07:00AM BLOOD Glucose-73 UreaN-20 Creat-0.9 Na-132* K-3.9 Cl-96 HCO3-24 AnGap-16 [MASKED] 07:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 [MASKED] 08:10AM BLOOD %HbA1c-10.3* eAG-249* Brief Hospital Course: [MASKED] with giant cell arteritis on prednisone presenting with rapidly progressive encephalopathy found to have metastatic lung adenocarcinoma s/p biopsy of adrenal mass with mets to leptomeninges, course complicated by anemia and tachycardia attributed to upper GI blood loss, now improved. Given poor prognosis, discharging with hospice. # Progressive Encephalopathy secondary to leptomeningeal involvement spread of malignancy: Significant concern for leptomeningeal carcinomatosis given elevated CSF opening pressure, elevated protein >200 and cell count, CSF cytology positive for malignant cells. Infectious workup negative, no seizures on EEG, no masses on imaging. Neuro-onc, heme-onc consulted and recommended dexamethasone for symptom based treatment, no other options available, poor prognosis. Started on dexamethasone 4mg BID with symptomatic improvement in mental status. Given hyperglycemic, evidence of blood loss, decreased dexamethasone to 2mg BID, mental status remained stable. Discussed with family that this can be further adjusted given that this is symptomatic treatment alone, however wished to keep current dose. - dexamethasone 2mg PO BID - pantoprazole 40mg PO BID # Metastatis lung adenocarcinoma: Former smoker, 20 pack year history. LLL mass, adrenal met and leptomeningeal spread. Heme-onc, neuro-onc consulted, unfortunately poor prognosis without treatment options. - DNR/DNI/no MICU transfer - MOLST signed [MASKED] with alternate HCP son in discussion by phone with wife - no active symptom management at this time, not eligible for GIP hospice - planned discharge with hospice - Tylenol [MASKED] PO TID, not requiring additional pain control # Anemia with acute blood loss with tachycardia: Resolved. Guaiac positive stool, on high dose steroids, no frank GI bleed or pulmonary symptoms, and no RP bleed on CT abd/pelvis, so suspect upper GI source. S/p 2u PRBCs with improvement in CBC, tachycardia. Increased PPI to BID, CBC stabilized and no longer checking given clinical stability and goals of care. - PPI BID - steroids at 2mg BID, can consider decrease to daily in the future - prn Maalox, Carafate for indigestion (not requiring) - discontinued aspirin given GI bleed # DMII/Hyperglycemia: With high dose steroids elevated FSBG requiring uptitration of lantus and Humalog, A1c >10, so likely hyperglycemic prior to admission as well and was on steroids prior to admission. Upon discharge, dexamethasone near pre-admission pred equivalent (26mg, was taking 20mg). With dexamethasone decrease, insulin downtitrated, transition back to PO glipizide upon discharge for ease of administration. - glipizide 5mg PO BID - daily FSBG monitoring be pursued but is not necessary given goals of care (FSBG <150 - hold glipizide; >400 10mg BID glipizide, otherwise maintain dose) - if not tolerating PO, please do not give glipizide # EKG abnormalities: Suspicion for prior MI, probably silent in setting of uncontrolled DMII, started on low dose metop 6.25mg BID, transitioned to 12.5mg XL upon discharge. # History of urinary retention s/p foley placement: Discussed with family. Prefer to leave foley in place for comfort, avoiding straight cath. Discussed that this can be revisited at any time and that he is at risk for infection with indwelling catheter. #Contact: Wife [MASKED], [MASKED] son [MASKED] [MASKED] [MASKED] stable for discharge home with hospice. > 30 minutes spent on discharge day services, counseling, and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 20 mg PO DAILY 2. GlipiZIDE 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO Frequency is Unknown 6. Vitamin D Dose is Unknown PO DAILY 7. Cyanocobalamin Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aluminum-Magnesium Hydrox.-Simethicone [MASKED] mL PO QID:PRN gas pain, indigestion 3. Dexamethasone 2 mg PO Q12H RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Metoprolol Succinate XL 12.5 mg PO DAILY RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation 9. GlipiZIDE 5 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Metastatic lung adenocarcinoma with adrenal metastasis and suspected Leptomeningeal carcinomatosis 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 admitted to the hospital with worsening confusion and were unfortunately found to have metastatic lung cancer, which has spread to the brain. You were started on steroids, which helped your symptoms. You were seen by the Neuro-oncologists and Medical Oncologists, and unfortunately there are no good treatment options, and with your family, the you are being transferred home for further care. We wish you the best. Followup Instructions: [MASKED]
[]
[ "E1165", "D62", "E871", "I252", "Z66", "Z794", "Z8673", "Z951", "Z87891", "K219", "D509", "E785" ]
[ "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "G9349: Other encephalopathy", "C7932: Secondary malignant neoplasm of cerebral meninges", "C7972: Secondary malignant neoplasm of left adrenal gland", "H4921: Sixth [abducent] nerve palsy, right eye", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D62: Acute posthemorrhagic anemia", "E871: Hypo-osmolality and hyponatremia", "I252: Old myocardial infarction", "Z66: Do not resuscitate", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z8674: Personal history of sudden cardiac arrest", "E781: Pure hyperglyceridemia", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "R195: Other fecal abnormalities", "R339: Retention of urine, unspecified", "I4510: Unspecified right bundle-branch block", "K5520: Angiodysplasia of colon without hemorrhage", "K219: Gastro-esophageal reflux disease without esophagitis", "R51: Headache", "D509: Iron deficiency anemia, unspecified", "E785: Hyperlipidemia, unspecified" ]
10,067,059
25,161,101
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right parasagittal frontal mass Major Surgical or Invasive Procedure: ___: Right craniotomy resection of dural lesion History of Present Illness: ___ female who presents with previous small cell lung cancer and a right parasagittal frontal mass, which was discovered on surveillance scan. The patient was initially diagnosed with non-small cell lung cancer of the left lung and was treated with lobectomy in ___, at ___. Right upper lobe lung nodules were negative, and she has been monitored with serial scans. Recent MRI demonstrated a probable parasagittal meningioma. Imaging revealed right parasagittal frontal mass, which is approximately 8 x 8 x 12 mm. This is likely meningioma, however, given her history, it is possible that it could be a dural based metastasis. Past Medical History: - smoking - lung cancer which was treated ___ - significant claustrophobia. Social History: ___ Family History: Unknown Physical Exam: ON DISCHARGE: ============ Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 3-2mm 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 ___ IPQuadHamATEHLGast ___ Left5 5 5 5 5 5 [x]Sensation intact to light touch Wound: [x]Clean, dry, intact [x]Staples Pertinent Results: Please refer to OMR for pertinent imaging and lab results Brief Hospital Course: ___ is a ___ year old female who had routine imaging done for her history of lung cancer, and found to have a right dural based lesion. She presents for elective surgical intervention. #Right Brain Tumor Patient presented to pre-op area, was assessed by anesthesia and taken to the OR on ___ for Right craniotomy for resection of dural based lesion. Patient tolerated the procedure well. Please refer to formal op report in OMR for further intra operative details. She was successfully extubated in the OR and taken to the PACU for post op where. She remained stable in PACU and was later transferred to the ___. Post op MRI was on POD1 and showed no residual tumor. She was discharged on POD2. At time of discharge, she remained neurologically intact, her pain was well controlled, she was eating/drinking at baseline, and she was ambulating in the hallways with steady gait with no difficulties. Medications on Admission: - alprazolam 0.25 mg tablet - (2 pills in AM, 1 at night) - cyclobenzaprine 10 mg tablet - 1 tab PO BID - fluoxetine 20 mg capsule - 1 cap PO BID - levothyroxine 25 mcg tablet - 1 tab PO daily - levothyroxine 88 mcg tablet - 1 tab PO daily - simvastatin 40 mg tablet - 1 tab PO QPM - Ambien 5 mg tablet - 1 tab PO QHS - multivitamin tablet - 1 tab PO daily - Fish Oil 360 mg-1,200 mg capsule - 1 cap PO daily Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Dexamethasone 4 mg PO Q12H Duration: 3 Doses 3. Dexamethasone 2 mg PO Q12H Duration: 4 Doses Tapered dose - DOWN RX *dexamethasone 2 mg 1 tablet(s) by mouth see taper Disp #*7 Tablet Refills:*0 4. Dexamethasone 2 mg PO DAILY Duration: 2 Doses Tapered dose - DOWN 5. Docusate Sodium 100 mg PO BID 6. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 7. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Post op orders RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as needed Disp #*10 Tablet Refills:*0 9. ALPRAZolam 0.25 mg PO BID:PRN anxiety Discharge Disposition: Home Discharge Diagnosis: Brain Tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery *** You underwent surgery to remove a brain lesion from your brain. * Please keep your incision dry until your staples are removed. * You may shower at this time but keep your incision dry. * It is best to keep your incision open to air but it is ok to cover it when outside. * Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity * We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. * You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. * No driving while taking any narcotic or sedating medication. * If you experienced a seizure while admitted, you are NOT allowed to drive by law. * No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications ***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. * You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. ***You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. ** Please follow-up with Dr ___ length of duration to take this medication. ** You were started on Dexamethasone to help with post-operative swelling. Please take 4mg once the night of discharge Pleas take 2mg twice a day for two days Please take 2mg once a day for two days Please take Famotidine twice a day to protect your stomach while taking steroids. What You ___ Experience: * You may experience headaches and incisional pain. * You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. * You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. * Feeling more tired or restlessness is 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. 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: ___
[ "D320", "C3492", "R918", "J449", "E039", "E669", "K219", "Z6830", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right parasagittal frontal mass Major Surgical or Invasive Procedure: [MASKED]: Right craniotomy resection of dural lesion History of Present Illness: [MASKED] female who presents with previous small cell lung cancer and a right parasagittal frontal mass, which was discovered on surveillance scan. The patient was initially diagnosed with non-small cell lung cancer of the left lung and was treated with lobectomy in [MASKED], at [MASKED]. Right upper lobe lung nodules were negative, and she has been monitored with serial scans. Recent MRI demonstrated a probable parasagittal meningioma. Imaging revealed right parasagittal frontal mass, which is approximately 8 x 8 x 12 mm. This is likely meningioma, however, given her history, it is possible that it could be a dural based metastasis. Past Medical History: - smoking - lung cancer which was treated [MASKED] - significant claustrophobia. Social History: [MASKED] Family History: Unknown Physical Exam: ON DISCHARGE: ============ Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 3-2mm 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 [MASKED] IPQuadHamATEHLGast [MASKED] Left5 5 5 5 5 5 [x]Sensation intact to light touch Wound: [x]Clean, dry, intact [x]Staples Pertinent Results: Please refer to OMR for pertinent imaging and lab results Brief Hospital Course: [MASKED] is a [MASKED] year old female who had routine imaging done for her history of lung cancer, and found to have a right dural based lesion. She presents for elective surgical intervention. #Right Brain Tumor Patient presented to pre-op area, was assessed by anesthesia and taken to the OR on [MASKED] for Right craniotomy for resection of dural based lesion. Patient tolerated the procedure well. Please refer to formal op report in OMR for further intra operative details. She was successfully extubated in the OR and taken to the PACU for post op where. She remained stable in PACU and was later transferred to the [MASKED]. Post op MRI was on POD1 and showed no residual tumor. She was discharged on POD2. At time of discharge, she remained neurologically intact, her pain was well controlled, she was eating/drinking at baseline, and she was ambulating in the hallways with steady gait with no difficulties. Medications on Admission: - alprazolam 0.25 mg tablet - (2 pills in AM, 1 at night) - cyclobenzaprine 10 mg tablet - 1 tab PO BID - fluoxetine 20 mg capsule - 1 cap PO BID - levothyroxine 25 mcg tablet - 1 tab PO daily - levothyroxine 88 mcg tablet - 1 tab PO daily - simvastatin 40 mg tablet - 1 tab PO QPM - Ambien 5 mg tablet - 1 tab PO QHS - multivitamin tablet - 1 tab PO daily - Fish Oil 360 mg-1,200 mg capsule - 1 cap PO daily Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever 2. Dexamethasone 4 mg PO Q12H Duration: 3 Doses 3. Dexamethasone 2 mg PO Q12H Duration: 4 Doses Tapered dose - DOWN RX *dexamethasone 2 mg 1 tablet(s) by mouth see taper Disp #*7 Tablet Refills:*0 4. Dexamethasone 2 mg PO DAILY Duration: 2 Doses Tapered dose - DOWN 5. Docusate Sodium 100 mg PO BID 6. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 7. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 8. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Post op orders RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as needed Disp #*10 Tablet Refills:*0 9. ALPRAZolam 0.25 mg PO BID:PRN anxiety Discharge Disposition: Home Discharge Diagnosis: Brain Tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery *** You underwent surgery to remove a brain lesion from your brain. * Please keep your incision dry until your staples are removed. * You may shower at this time but keep your incision dry. * It is best to keep your incision open to air but it is ok to cover it when outside. * Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity * We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. * You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. * No driving while taking any narcotic or sedating medication. * If you experienced a seizure while admitted, you are NOT allowed to drive by law. * No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications ***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. * You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. ***You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. ** Please follow-up with Dr [MASKED] length of duration to take this medication. ** You were started on Dexamethasone to help with post-operative swelling. Please take 4mg once the night of discharge Pleas take 2mg twice a day for two days Please take 2mg once a day for two days Please take Famotidine twice a day to protect your stomach while taking steroids. What You [MASKED] Experience: * You may experience headaches and incisional pain. * You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. * You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. * Feeling more tired or restlessness is 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. 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]
[]
[ "J449", "E039", "E669", "K219", "Z87891" ]
[ "D320: Benign neoplasm of cerebral meninges", "C3492: Malignant neoplasm of unspecified part of left bronchus or lung", "R918: Other nonspecific abnormal finding of lung field", "J449: Chronic obstructive pulmonary disease, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z6830: Body mass index [BMI]30.0-30.9, adult", "Z87891: Personal history of nicotine dependence" ]
10,067,086
28,293,892
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache and fever Major Surgical or Invasive Procedure: LUMBAR PUNCTURE (___) History of Present Illness: ___ y.o. F with no significant PMH who presented with a 1-day history of HA, vomiting, and fever. The patient was in her usual state of health until ___ (___), when she began to experience chills and muscle aches. The day prior to ___, she experienced a headache that awoke her from sleep. She describes the headache as a ___ throbbing pain that she has never experienced before. It was associated with neck pain. She denies aura, visual changes, and photophobia associated with the headache. It improved slightly with Tylenol and worsened with sitting up or any exertion. When her headache continued to worsen and she had three episodes of vomiting with yellowish emesis, she decided to present to the ED. In the ED, initial vitals: T 101.8 BP 121/70 HR 89 RR 18 SaO2 97% RA Labs were significant for: CSF with Protein 137 Glu 46 WBCs 517 (88% lymph) CSF with negative gram stain, +2 PMNs BCx x2 pending No imaging acquired. In the ED, she received CTX 2g, vanc 1g, 1L NS ROS: No night sweats or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No abdominal pain. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. ID ROS: She denies any sick contacts. She recently returned on ___ from a 10-day trip to ___, ___. She denies any contact with livestock, farms, ticks, mosquitoes, or other insects. She did not do any watersports in ___. She lives in a house in the city with 5 other roommates, none of whom have been ill. She recently started her ___ year of college last week. She is not sexually active and denies any partners over the past year. Past Medical History: History of depression, not currently on medications Social History: ___ Family History: None known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.9 BP 113/59 HR 61 RR 18 SaO2 99% RA GEN: Young woman lying in bed with lights turned off, uncomfortable but no acute distress, warm to the touch. HEENT: Dry MM, anicteric sclerae, no conjunctival pallor. NECK: Stiffness with head movement, no LAD. PULM: Generally CTA b/l in anterior lung fields without wheeze or rhonchi. COR: RRR (+)S1/S2, ___ SEM at ___. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTREM: Cool distally and warm proximally, well-perfused, no edema, +1 ___ pulses. NEURO: CN II-XII intact, ___ strength in bilateral UE, ___ strength in bilateral ___. sensation to light touch preserved throughout all extremities. +jolt accentuation. -Kernig sign. SKIN: No rash. ACCESS: 20G IV DISCHARGE PHYSICAL EXAM: ======================== VS: T 98.3 BP 113/60 HR 59 RR 19 SaO2 99% RA GEN: Young woman lying in bed, no acute distress. HEENT: MMM, anicteric sclerae, no conjunctival pallor. NECK: Full ROM, no LAD. PULM: Generally CTA b/l in anterior lung fields without wheeze or rhonchi. COR: RRR (+)S1/S2, ___ SEM at ___. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTREM: Warm, well-perfused, no edema, +1 ___ pulses. NEURO: CN II-XII intact, ___ strength in bilateral UE, ___ strength in bilateral ___. sensation to light touch preserved throughout all extremities. SKIN: ___ pinpoint lesions in the webspace of ___ toes on R foot. Patient reports pruritic. GU: ___ pinpoint lesions on the labia minora, exam limited by menstrual blood. ACCESS: 20G IV Pertinent Results: CSF WBC 378-517 Lymph ___ Protein 137 Glucose 46 CSF HSV PCR - POSITIVE FOR HSV 2 CSF VZV PCR - negative CSF enterovirus - negative RPR - negative Lyme IgG and IgM - negative Blood cultures: final result pending, but no growth five days Urine GC/Ct PCR - pending at discharge Brief Hospital Course: ___ y.o. F with no significant PMH who presents with a 1-day history of HA, vomiting, and fever, confirmed to be HSV-2 viral meningitis. ACTIVE ISSUES: -------------- # ___ Meningitis: Lumbar puncture performed (___) with pleocytosis with lymphocytic predominance, elevated CSF protein, and negative gram stain. CT Head (___) without acute intracranial process or evidence of herniation. Patient maintained on ceftriaxone (___), vancomycin (___), and acyclovir (___) to cover bacterial and viral pathogens. CSF positive for HSV-2 on ___. External genitalia exam notable for a few pinpoint ? vesicular lesions on the labia minora, although limited by menstrual blood. Headache managed with Tylenol and oxycodone unsuccessfully, but responded well to Toradol and other NSAIDs. No seizures or focal neurological deficits during admission. On discharge, the patient had no headache, was tolerating POs well, and was able to ambulate well. RESOLVED ISSUES: ---------------- # Anemia: Likely mixed dilutational and marrow suppression in the setting of acute illness. Given continued downtrending with stable WBC and improving Plt count, ordered LDH and retics. RPI 0.42, LD low (consistent with deficiency of H form of LDH, which is totally asymptomatic). - CTM # Thrombocytopenia (resolved): 135 on ___ on ___. Likely dilutional given downtrending of all cell lines on ___. Less likely antibiotic (e.g., vancomycin) or viral effect. - CTM TRANSITIONAL ISSUES: -------------------- # Valacyclovir 500mg BID for 14 day total course (last day is ___. - No suppression required for meningitis, but still could be considered for genital lesions if patient is interested. # Smoking: Patient reports smoking ___ packs per week. Will perform motivational interviewing prior to DC, recommend quitting, and offer nicotine patch. PCP should continue to encourage quitting. # Ibuprofen/ranitidine: Patient written for 1x week of ibuprofen and ranitidine for headache and gastric prophylaxis, respectively. # HSV-2: Scheduled for outpatient OB/Gyn follow-up with Dr. ___ ___ on ___, but alternatively may utilize OB/Gyn on campus. Encouraged to be open with provider regarding safe sexual practices, IUD, and STI testing. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 500 mg 2 tablet(s) by mouth Three times a day Disp #*90 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*0 3. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Moderate Duration: 1 Week RX *ibuprofen 200 mg 2 tablet(s) by mouth Every ___ hours Disp #*84 Tablet Refills:*0 4. Ondansetron 4 mg PO ONCE nausea Duration: 1 Dose RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 5. Ranitidine 150 mg PO BID Duration: 1 Week RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a day Disp #*14 Tablet Refills:*0 6. ValACYclovir 500 mg PO Q12H Duration: 11 Days RX *valacyclovir 500 mg 1 tablet(s) by mouth Twice a day Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: VIRAL MENINGITIS DUE TO HERPES SIMPLEX VIRUS 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with meningitis, an infection of the membranes surrounding the brain. This infection is most often caused by a bacteria or a virus. We treated you for both bacteria and viruses while we were waiting for test results. We now know that your infection was caused by herpes simplex virus (HSV2). This is a common infection usually transmitted through sexual contact. It is controlled with medicines. In the future, you may need to take either suppressive therapy (a pill everyday) or episodic therapy (pills only when you have a recurrence). Please continue to take all medications as prescribed. Valacyclovir will be taken until ___. It is very important to finish the entire course of antiviral medications to prevent recurrence of your meningitis. Warmly, Your ___ ___ Team Followup Instructions: ___
[ "B003", "D696", "D649", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Headache and fever Major Surgical or Invasive Procedure: LUMBAR PUNCTURE ([MASKED]) History of Present Illness: [MASKED] y.o. F with no significant PMH who presented with a 1-day history of HA, vomiting, and fever. The patient was in her usual state of health until [MASKED] ([MASKED]), when she began to experience chills and muscle aches. The day prior to [MASKED], she experienced a headache that awoke her from sleep. She describes the headache as a [MASKED] throbbing pain that she has never experienced before. It was associated with neck pain. She denies aura, visual changes, and photophobia associated with the headache. It improved slightly with Tylenol and worsened with sitting up or any exertion. When her headache continued to worsen and she had three episodes of vomiting with yellowish emesis, she decided to present to the ED. In the ED, initial vitals: T 101.8 BP 121/70 HR 89 RR 18 SaO2 97% RA Labs were significant for: CSF with Protein 137 Glu 46 WBCs 517 (88% lymph) CSF with negative gram stain, +2 PMNs BCx x2 pending No imaging acquired. In the ED, she received CTX 2g, vanc 1g, 1L NS ROS: No night sweats or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No abdominal pain. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. ID ROS: She denies any sick contacts. She recently returned on [MASKED] from a 10-day trip to [MASKED], [MASKED]. She denies any contact with livestock, farms, ticks, mosquitoes, or other insects. She did not do any watersports in [MASKED]. She lives in a house in the city with 5 other roommates, none of whom have been ill. She recently started her [MASKED] year of college last week. She is not sexually active and denies any partners over the past year. Past Medical History: History of depression, not currently on medications Social History: [MASKED] Family History: None known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.9 BP 113/59 HR 61 RR 18 SaO2 99% RA GEN: Young woman lying in bed with lights turned off, uncomfortable but no acute distress, warm to the touch. HEENT: Dry MM, anicteric sclerae, no conjunctival pallor. NECK: Stiffness with head movement, no LAD. PULM: Generally CTA b/l in anterior lung fields without wheeze or rhonchi. COR: RRR (+)S1/S2, [MASKED] SEM at [MASKED]. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTREM: Cool distally and warm proximally, well-perfused, no edema, +1 [MASKED] pulses. NEURO: CN II-XII intact, [MASKED] strength in bilateral UE, [MASKED] strength in bilateral [MASKED]. sensation to light touch preserved throughout all extremities. +jolt accentuation. -Kernig sign. SKIN: No rash. ACCESS: 20G IV DISCHARGE PHYSICAL EXAM: ======================== VS: T 98.3 BP 113/60 HR 59 RR 19 SaO2 99% RA GEN: Young woman lying in bed, no acute distress. HEENT: MMM, anicteric sclerae, no conjunctival pallor. NECK: Full ROM, no LAD. PULM: Generally CTA b/l in anterior lung fields without wheeze or rhonchi. COR: RRR (+)S1/S2, [MASKED] SEM at [MASKED]. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTREM: Warm, well-perfused, no edema, +1 [MASKED] pulses. NEURO: CN II-XII intact, [MASKED] strength in bilateral UE, [MASKED] strength in bilateral [MASKED]. sensation to light touch preserved throughout all extremities. SKIN: [MASKED] pinpoint lesions in the webspace of [MASKED] toes on R foot. Patient reports pruritic. GU: [MASKED] pinpoint lesions on the labia minora, exam limited by menstrual blood. ACCESS: 20G IV Pertinent Results: CSF WBC 378-517 Lymph [MASKED] Protein 137 Glucose 46 CSF HSV PCR - POSITIVE FOR HSV 2 CSF VZV PCR - negative CSF enterovirus - negative RPR - negative Lyme IgG and IgM - negative Blood cultures: final result pending, but no growth five days Urine GC/Ct PCR - pending at discharge Brief Hospital Course: [MASKED] y.o. F with no significant PMH who presents with a 1-day history of HA, vomiting, and fever, confirmed to be HSV-2 viral meningitis. ACTIVE ISSUES: -------------- # [MASKED] Meningitis: Lumbar puncture performed ([MASKED]) with pleocytosis with lymphocytic predominance, elevated CSF protein, and negative gram stain. CT Head ([MASKED]) without acute intracranial process or evidence of herniation. Patient maintained on ceftriaxone ([MASKED]), vancomycin ([MASKED]), and acyclovir ([MASKED]) to cover bacterial and viral pathogens. CSF positive for HSV-2 on [MASKED]. External genitalia exam notable for a few pinpoint ? vesicular lesions on the labia minora, although limited by menstrual blood. Headache managed with Tylenol and oxycodone unsuccessfully, but responded well to Toradol and other NSAIDs. No seizures or focal neurological deficits during admission. On discharge, the patient had no headache, was tolerating POs well, and was able to ambulate well. RESOLVED ISSUES: ---------------- # Anemia: Likely mixed dilutational and marrow suppression in the setting of acute illness. Given continued downtrending with stable WBC and improving Plt count, ordered LDH and retics. RPI 0.42, LD low (consistent with deficiency of H form of LDH, which is totally asymptomatic). - CTM # Thrombocytopenia (resolved): 135 on [MASKED] on [MASKED]. Likely dilutional given downtrending of all cell lines on [MASKED]. Less likely antibiotic (e.g., vancomycin) or viral effect. - CTM TRANSITIONAL ISSUES: -------------------- # Valacyclovir 500mg BID for 14 day total course (last day is [MASKED]. - No suppression required for meningitis, but still could be considered for genital lesions if patient is interested. # Smoking: Patient reports smoking [MASKED] packs per week. Will perform motivational interviewing prior to DC, recommend quitting, and offer nicotine patch. PCP should continue to encourage quitting. # Ibuprofen/ranitidine: Patient written for 1x week of ibuprofen and ranitidine for headache and gastric prophylaxis, respectively. # HSV-2: Scheduled for outpatient OB/Gyn follow-up with Dr. [MASKED] [MASKED] on [MASKED], but alternatively may utilize OB/Gyn on campus. Encouraged to be open with provider regarding safe sexual practices, IUD, and STI testing. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 500 mg 2 tablet(s) by mouth Three times a day Disp #*90 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*0 3. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Moderate Duration: 1 Week RX *ibuprofen 200 mg 2 tablet(s) by mouth Every [MASKED] hours Disp #*84 Tablet Refills:*0 4. Ondansetron 4 mg PO ONCE nausea Duration: 1 Dose RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 5. Ranitidine 150 mg PO BID Duration: 1 Week RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a day Disp #*14 Tablet Refills:*0 6. ValACYclovir 500 mg PO Q12H Duration: 11 Days RX *valacyclovir 500 mg 1 tablet(s) by mouth Twice a day Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: VIRAL MENINGITIS DUE TO HERPES SIMPLEX VIRUS 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with meningitis, an infection of the membranes surrounding the brain. This infection is most often caused by a bacteria or a virus. We treated you for both bacteria and viruses while we were waiting for test results. We now know that your infection was caused by herpes simplex virus (HSV2). This is a common infection usually transmitted through sexual contact. It is controlled with medicines. In the future, you may need to take either suppressive therapy (a pill everyday) or episodic therapy (pills only when you have a recurrence). Please continue to take all medications as prescribed. Valacyclovir will be taken until [MASKED]. It is very important to finish the entire course of antiviral medications to prevent recurrence of your meningitis. Warmly, Your [MASKED] [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D696", "D649", "F17210" ]
[ "B003: Herpesviral meningitis", "D696: Thrombocytopenia, unspecified", "D649: Anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,067,195
21,564,201
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Chief Complaint: acute blood loss anemia Major Surgical or Invasive Procedure: ERCP with biliary and CBD stenting (___) EGD (___) History of Present Illness: ___ female with a history of PE, pancreatic cancer with metastases to the liver currently on chemotherapy, recent MI 2 weeks ago w/ PCI, transferred from outside hospital with acute weakness found to be acutely anemic. Patient reports 1 week of gradual worsening general weakness, also worsening jaundice. On the day of admission, she developed bilious vomiting and significant weakness. She went to an outside hospital where vitals were notable for hypotensive to ___, labs notable for H/H ___, WBC 22, guaiac positive stool. She received a blood transfusion and was transferred here for intensive care. Patient was recently diagnosed with pancreatic cancer in ___ after being diagnosed with a PE, found to have pancreatic cancer with metastases to liver. 2 weeks ago, while in ___ clinic developed acute chest pain was diagnosed with MI. Patient has been on Xarelto for PE since diagnosis. Denies melena or bloody stools. Denies hematemesis, active chest pain, or shortness of breath. Oncologic History (per ___ records): - ___: CTAP showed 2.4x1.6 mass of the uncinate process of the pancrease, multiple hepatic metastases - ___: CT angio of chest with multiple bilateral PEs, especially to the right base. Patient placed on Xarelto - ___ was > 200,000 - ___ Liver biopsy (core needle): adenocarcinoma. NextGen sequencing showing pancreatobiliary source. -___: readmitted with left flank pain, CT AP stable, but showing possible left lung infarct. Port-A-Cath placed. Due to residual DVTs of the lower extremity, an IVC filter was placed. Xarelto continued. Ultrasound of the liver showed new mild intrahepatic ductal dilatation (CBD 12.5mm). No evidence gallstones or cholecystitis. Pancreatic duct dilated to 5mm. Plan was for stent with Dr. ___ at ___, however, she developed a STEMI and this was deferred. Patient underwent PCI and was placed on DAPT. -___: C1 Folfirinox -___: C1D1 Gemzar (weekly x3, with 1 week off). Pt was noted to have rising bilirubin, jaundice, for which she was sent for RUQUS to evaluate for obstruction. In the ED, - Initial Vitals: T 97.8 70 BP 106/64 RR 20 SpO2 97% RA - Exam: jaundiced abdomen soft, non tender, no ascites on POCUS no leg edema - Labs: INR 10 Tbili 12 Dbili 9.7 ALP 1317 ALT: 178 AST: 504 WBC 20 Trop-T 0.05 Lactate:1.1 - Imaging: ___ RUQUS: 1. Patent portal vasculature. 2. The known pancreatic head mass is partially seen, measuring approximately 1.5 x 2.0 x 1.7 cm, with associated biliary and pancreatic ductal dilatation. 3. Multiple ill-defined predominantly hypoechoic to isoechoic hepatic lesions are presumed metastasis. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. - Consults: GI who recommended cross-sectional imaging to eval for intra-abdominal source of bleeding, further work up of anemia (including possible chemotherapy reaction), agree with resuscitative measures, call/page for unstable bleeding. - Interventions: 3 units of pRBCs ___ 04:55 IV Pantoprazole 40 mg ___ 07:21 IV Ondansetron 4 mg ___ 07:21 IV Phytonadione - Transfer labs: T 98.1 HR 69 BP 103/56 RR 16 SpO2 96% RA Past Medical History: - Left ACL repair (___) - Hysterectomy / BSO for uterine fibroids (___) - Pancreatic Adenocarcinoma Social History: ___ Family History: not obtained Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.2 66 100/65 20 94% on RA GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: unlabored, CTAB GI: abd soft, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis DISCHARGE PHYSICAL EXAM GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: CTAB GI: abd soft, tenderness to palpation in RUQ, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis Pertinent Results: ADMISSION LABS ___ 03:48AM BLOOD WBC-20.2* RBC-1.93* Hgb-5.8* Hct-18.2* MCV-94 MCH-30.1 MCHC-31.9* RDW-16.7* RDWSD-54.9* Plt ___ ___ 03:48AM BLOOD ___ PTT-34.0 ___ ___ 03:48AM BLOOD Glucose-133* UreaN-22* Creat-0.6 Na-135 K-4.4 Cl-99 HCO3-23 AnGap-13 ___ 03:48AM BLOOD ALT-178* AST-504* LD(LDH)-610* AlkPhos-1317* TotBili-12.1* DirBili-9.7* IndBili-2.4 ___ 03:48AM BLOOD cTropnT-0.05* ___ 10:55AM BLOOD CK-MB-2 cTropnT-0.06* ___ 03:48AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.4 Mg-1.9 ___ 11:42AM BLOOD ___ pO2-34* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 ___ 03:56AM BLOOD Lactate-1.1 ___ 11:42AM BLOOD Lactate-1.8 MICRO UCx (___): skin contamination, otherwise no growth BCx x2 (___): 1 bottle NGTD, 1 bottle w GPC in pairs/clusters: ___ 3:48 am BLOOD CULTURE # 1 VENI. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ AT 1808 ON ___. IMAGING RUQ US ___ 1. Patent portal vasculature. Please note that the SMV, splenic, and arterial vasculature are not evaluated with this technique. 2. Enlarged peripancreatic lymph node. 3. A few ill-defined iso-to-hypoechoic hepatic lesions and one discrete hyperechoic lesion are incompletely characterized, but concerning for metastatic disease, not optimally evaluated with this technique. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. EGD ___: - esophagitis was seen in distal esophagus - large hiatal hernia seen in stomach with an area of active oozing seen in proximal part of hiatal hernia - several areas of active oozing in duodenum - successful ERCP with biliary metal stent placement Recommendations: 1. follow up with referring physician 2. PPI 40 mg twice daily 3. ongoing control of coagulopathic state 4. repeat ERCP in 2 weeks. If repeat EGD is planned, the PD stent can be pulled out during that exam. TTE ___ Right atrial mass (see above). Normal left ventricular cavity size with mild regional systolic dysfunction most consistent with coronary artery disease (LCx distribution). Moderate functional mitral regurgitation (Carptenier IIIb). No prior TTE available for comparison but imaging at OSH reported this finding according to requisition. Recommend review of prior imaging to see if TEE or CMR performed. DISCHARGE LABS ___ 06:06AM BLOOD WBC-20.7* RBC-3.01* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.5 RDWSD-47.2* Plt Ct-71* ___ 02:01AM BLOOD ___ PTT-22.6* ___ ___ 02:01AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-131* K-4.1 Cl-97 HCO3-22 AnGap-12 ___ 02:01AM BLOOD ALT-145* AST-374* LD(LDH)-609* AlkPhos-1483* TotBili-15.6* ___ 02:01AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 Brief Hospital Course: PATIENT SUMMARY =============== Ms. ___ is a ___ year-old woman with a PMH of newly diagnosed pancreatic cancer and known liver metastases, currently receiving chemotherapy, who presented with fatigue and vomiting, found to have acute anemia (Hg 3.8), admitted to the ICU for close monitoring and resuscitation. She was transfused 3 units in total with recovery of Hg to 8.9. She underwent EGD with epinephrine injection of an area of oozing near a hiatal hernia. She concurrently underwent ERCP with placement of a bare metal stent and a PD stent to relieve her biliary obstruction. Her Xarelto was held throughout the admission given UGIB. The decision regarding restarting it will require further discussion with cardiology. Finally, a family meeting was held with palliative care to discuss prognosis and goals of care (she will ultimately need to decide whether to continue chemotherapy or not). #Acute Blood Loss Anemia Patient had guaiac positive stool in the ED. GI bleed was in the setting of DAPT + xarelto, but no history of prior GIBs, and drinking history in past but never diagnosed with cirrhosis. Hemolysis labs negative. She was placed on IV PPI. She received a total of 3 units pRBCs and 1 unit plasma. GI was consulted and performed EGD during ERCP, which showed GEJ oozing with no obvious lesions and oozing from several erosions in the small intestine with no clear lesion. She was transfused for threshold of Hg <8 given recent MI. #Pancreatic Cancer, Stage IV #Transaminitis #Hyperbilirubinemia #Abdominal Pain / Constipation #Malnutrition Prior to hospitalization, patient had biopsy of liver metastasis revealing adenocarcinoma of pancreaticobiliary origin. She is followed by Dr. ___ at ___. S/p Fosfirinox x1, which was poorly tolerated. She was switched to ___ on ___. She had known biliary/pancreatic duct obstruction, and had been planning for ERCP/stent placement on ___ at ___, but this was delayed due to anticoagulation requirement. ERCP was performed on ___ at ___ along with EGD, biliary stents were placed and obstruction was relieved. Her pain was treated with morphine and dilaudid. Nausea was treated with Zofran, prochlorperazine. She continued to receive lorazepam, senna, docusate. Nutrition consult was placed for malnutrition. A 5 day course of Unasyn was started due to concern for cholangitis. Patient had improvement of symptoms after ERCP. Encouraged PO intake as tolerated. #Hx PE #Intracardial clot #Elevated INR Provoked in setting of active malignancy. INR 10 on admission, s/p Vit K with improvement in coagulopathy. Likely contribution of poor PO intake and cholestasis-induced liver injury. No hypoxia or calf tenderness on admission. IVC filter in place. Reported history of intracardiac clot. TTE on ___ with possible thrombus vs tumor at the IVC/RA junction. Prior TEE from ___ showed intracardial clot, consistent with this TTE finding. Given this, she will likely need to continue anticoagulation on discharge. ___ was held on discharge from ___. Will require conversation to assess risks and benefits of restarting anticoagulation. #Leukocytosis: #Single positive blood culture Patient currently on chemotherapy, last WBC was 6.4 on ___. Currently without clear localizing cause. Has chronic abdominal pain, which has not changed over past week. Most likely from cholestasis as there was finding of thickened bile prior to relief of biliary obstruction on ERCP. One blood culture from ___ turned positive on the ___ prior to transfer, growing GPCs in pairs and clusters. Patient has been afebrile and clinically improving, therefore suspect contamination. Unasyn continued for anticipated 5d course #___ Patient with recent diagnosis of metastatic cancer. She has had a difficult time coping with the diagnosis and dealt with a lot of denial. In addition, she lives with her sister who explains that she is having difficulty caring for her at home. Brother is concerned about her home situation. Palliative care and social work were consulted. During an extensive family meeting, several options were laid out: 1) return home with increased ___ services to help offload family members 2) nursing home 3)as her disease progresses, consideration of hospice whether inpatient or outpatient. No unified decision was made. Patient understand the role of palliative care in helping improve her quality of life a bit better and will require very close outpatient follow up once she is discharged. She will additionally need to follow up closely with her oncologist regarding expectations surrounding cancer diagnosis. #CAD s/p MI w PCI Developed STEMI while hospitalized at ___ in ___. Mild troponin elevation 0.05, flat on re-check, with normal MB. No chest pain. She was continued on aspirin 81, Plavix 75. Metoprolol was held during this hospitalization. #Anxiety: She was continued on Sertraline and Bupropion daily TRANSITIONAL ISSUES ===================== #Biliary obstruction s/p stenting [] Will need repeat ERCP in 2 weeks at ___ for possible PD stent removal [] Unasyn 5d course (___) #Hx PE and atrial clot on AC [] Anticoagulation (home Xarelto) was held in the setting of GI bleed, will need to have conversation regarding risks of holding anticoagulation in the setting of intracardial clot vs risk of rebleeding if it is restarted. Patient has known atrial clot discovered on TTE/TEE at ___. #Palliative Care / Advanced Care Planning [] Recommend inpatient palliative care consult with transition to outpatient pall care. Family was specifically interested in being connected with a specialized social worker to help patient/family cope with diagnosis. [] Will require close follow up with her oncologist Dr. ___ ___ expectations for her prognosis to assist in advanced care planning. [] Patient's family has been struggling to provide adequate care at home (lives with sister, patient wants to be very independent). They will benefit from increased ___ services and discussion of possible placement in SNF. Ultimately hospice will be a good option for patient, particularly if her oncologist reports a poor prognosis. #CAD [] Metoprolol was held on discharge in the setting of low SBPs. Was likely initiated for cardioprotection s/p MI, consider the value of this medication given overall poor prognosis from pancreatic cancer. #Code: full code for now (will require further discussion as disease progresses) #Contact: brother ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS ___ 15 mg PO Q12H 2. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 3. Senna 8.6 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 5. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 6. LORazepam 0.5 mg PO Q6H:PRN anxiety 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 8. Sertraline 100 mg PO DAILY 9. BuPROPion XL (Once Daily) 300 mg PO DAILY 10. Clopidogrel 75 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Rivaroxaban 15 mg PO DAILY 13. Metoprolol Tartrate 12.5 mg PO BID Discharge Medications: 1. Ampicillin-Sulbactam 3 g IV Q6H Duration: 5 Days 2. Pantoprazole 40 mg PO Q12H 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. BuPROPion XL (Once Daily) 300 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 8. LORazepam 0.5 mg PO Q6H:PRN anxiety 9. Morphine SR (MS ___ 15 mg PO Q12H 10. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 11. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 12. Senna 8.6 mg PO DAILY 13. Sertraline 100 mg PO DAILY 14. HELD- Metoprolol Tartrate 12.5 mg PO BID This medication was held. Do not restart Metoprolol Tartrate until your doctor tells you to 15. HELD- Rivaroxaban 15 mg PO DAILY This medication was held. Do not restart Rivaroxaban until your doctor tells you to Discharge Disposition: Extended Care Discharge Diagnosis: metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: It was a pleasure caring for you at ___! Why did you come to the hospital? You came to the hospital because you felt weak and were noted to have very low blood levels. When this was noticed, you were transferred from ___ to the ___ ICU for intensive care. What did we do for you while you were here? We gave you several units of blood to help increase your blood levels. The gastroenterologists did a procedure and placed stents to help relieve the obstruction in your liver. You felt much better so you were discharged back to ___ so you could be closer to home and with your primary doctors. What should you do when you leave the hospital? You should be sure to follow up with the gastroenterologists. They have recommended that you return for a repeat of the procedure in 2 weeks to make sure that the obstruction continues to be open. You should also follow closely with the palliative care doctors. Followup Instructions: ___
[ "K921", "I213", "K831", "C250", "C787", "C786", "D62", "D684", "K8309", "E46", "Z86711", "Z7901", "I2510", "Z955", "Z7902", "Z87891", "F419", "K449", "D72829" ]
Allergies: oxycodone Chief Complaint: acute blood loss anemia Major Surgical or Invasive Procedure: ERCP with biliary and CBD stenting ([MASKED]) EGD ([MASKED]) History of Present Illness: [MASKED] female with a history of PE, pancreatic cancer with metastases to the liver currently on chemotherapy, recent MI 2 weeks ago w/ PCI, transferred from outside hospital with acute weakness found to be acutely anemic. Patient reports 1 week of gradual worsening general weakness, also worsening jaundice. On the day of admission, she developed bilious vomiting and significant weakness. She went to an outside hospital where vitals were notable for hypotensive to [MASKED], labs notable for H/H [MASKED], WBC 22, guaiac positive stool. She received a blood transfusion and was transferred here for intensive care. Patient was recently diagnosed with pancreatic cancer in [MASKED] after being diagnosed with a PE, found to have pancreatic cancer with metastases to liver. 2 weeks ago, while in [MASKED] clinic developed acute chest pain was diagnosed with MI. Patient has been on Xarelto for PE since diagnosis. Denies melena or bloody stools. Denies hematemesis, active chest pain, or shortness of breath. Oncologic History (per [MASKED] records): - [MASKED]: CTAP showed 2.4x1.6 mass of the uncinate process of the pancrease, multiple hepatic metastases - [MASKED]: CT angio of chest with multiple bilateral PEs, especially to the right base. Patient placed on Xarelto - [MASKED] was > 200,000 - [MASKED] Liver biopsy (core needle): adenocarcinoma. NextGen sequencing showing pancreatobiliary source. -[MASKED]: readmitted with left flank pain, CT AP stable, but showing possible left lung infarct. Port-A-Cath placed. Due to residual DVTs of the lower extremity, an IVC filter was placed. Xarelto continued. Ultrasound of the liver showed new mild intrahepatic ductal dilatation (CBD 12.5mm). No evidence gallstones or cholecystitis. Pancreatic duct dilated to 5mm. Plan was for stent with Dr. [MASKED] at [MASKED], however, she developed a STEMI and this was deferred. Patient underwent PCI and was placed on DAPT. -[MASKED]: C1 Folfirinox -[MASKED]: C1D1 Gemzar (weekly x3, with 1 week off). Pt was noted to have rising bilirubin, jaundice, for which she was sent for RUQUS to evaluate for obstruction. In the ED, - Initial Vitals: T 97.8 70 BP 106/64 RR 20 SpO2 97% RA - Exam: jaundiced abdomen soft, non tender, no ascites on POCUS no leg edema - Labs: INR 10 Tbili 12 Dbili 9.7 ALP 1317 ALT: 178 AST: 504 WBC 20 Trop-T 0.05 Lactate:1.1 - Imaging: [MASKED] RUQUS: 1. Patent portal vasculature. 2. The known pancreatic head mass is partially seen, measuring approximately 1.5 x 2.0 x 1.7 cm, with associated biliary and pancreatic ductal dilatation. 3. Multiple ill-defined predominantly hypoechoic to isoechoic hepatic lesions are presumed metastasis. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. - Consults: GI who recommended cross-sectional imaging to eval for intra-abdominal source of bleeding, further work up of anemia (including possible chemotherapy reaction), agree with resuscitative measures, call/page for unstable bleeding. - Interventions: 3 units of pRBCs [MASKED] 04:55 IV Pantoprazole 40 mg [MASKED] 07:21 IV Ondansetron 4 mg [MASKED] 07:21 IV Phytonadione - Transfer labs: T 98.1 HR 69 BP 103/56 RR 16 SpO2 96% RA Past Medical History: - Left ACL repair ([MASKED]) - Hysterectomy / BSO for uterine fibroids ([MASKED]) - Pancreatic Adenocarcinoma Social History: [MASKED] Family History: not obtained Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.2 66 100/65 20 94% on RA GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: unlabored, CTAB GI: abd soft, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis DISCHARGE PHYSICAL EXAM GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: CTAB GI: abd soft, tenderness to palpation in RUQ, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis Pertinent Results: ADMISSION LABS [MASKED] 03:48AM BLOOD WBC-20.2* RBC-1.93* Hgb-5.8* Hct-18.2* MCV-94 MCH-30.1 MCHC-31.9* RDW-16.7* RDWSD-54.9* Plt [MASKED] [MASKED] 03:48AM BLOOD [MASKED] PTT-34.0 [MASKED] [MASKED] 03:48AM BLOOD Glucose-133* UreaN-22* Creat-0.6 Na-135 K-4.4 Cl-99 HCO3-23 AnGap-13 [MASKED] 03:48AM BLOOD ALT-178* AST-504* LD(LDH)-610* AlkPhos-1317* TotBili-12.1* DirBili-9.7* IndBili-2.4 [MASKED] 03:48AM BLOOD cTropnT-0.05* [MASKED] 10:55AM BLOOD CK-MB-2 cTropnT-0.06* [MASKED] 03:48AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.4 Mg-1.9 [MASKED] 11:42AM BLOOD [MASKED] pO2-34* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 [MASKED] 03:56AM BLOOD Lactate-1.1 [MASKED] 11:42AM BLOOD Lactate-1.8 MICRO UCx ([MASKED]): skin contamination, otherwise no growth BCx x2 ([MASKED]): 1 bottle NGTD, 1 bottle w GPC in pairs/clusters: [MASKED] 3:48 am BLOOD CULTURE # 1 VENI. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [MASKED] AT 1808 ON [MASKED]. IMAGING RUQ US [MASKED] 1. Patent portal vasculature. Please note that the SMV, splenic, and arterial vasculature are not evaluated with this technique. 2. Enlarged peripancreatic lymph node. 3. A few ill-defined iso-to-hypoechoic hepatic lesions and one discrete hyperechoic lesion are incompletely characterized, but concerning for metastatic disease, not optimally evaluated with this technique. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. EGD [MASKED]: - esophagitis was seen in distal esophagus - large hiatal hernia seen in stomach with an area of active oozing seen in proximal part of hiatal hernia - several areas of active oozing in duodenum - successful ERCP with biliary metal stent placement Recommendations: 1. follow up with referring physician 2. PPI 40 mg twice daily 3. ongoing control of coagulopathic state 4. repeat ERCP in 2 weeks. If repeat EGD is planned, the PD stent can be pulled out during that exam. TTE [MASKED] Right atrial mass (see above). Normal left ventricular cavity size with mild regional systolic dysfunction most consistent with coronary artery disease (LCx distribution). Moderate functional mitral regurgitation (Carptenier IIIb). No prior TTE available for comparison but imaging at OSH reported this finding according to requisition. Recommend review of prior imaging to see if TEE or CMR performed. DISCHARGE LABS [MASKED] 06:06AM BLOOD WBC-20.7* RBC-3.01* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.5 RDWSD-47.2* Plt Ct-71* [MASKED] 02:01AM BLOOD [MASKED] PTT-22.6* [MASKED] [MASKED] 02:01AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-131* K-4.1 Cl-97 HCO3-22 AnGap-12 [MASKED] 02:01AM BLOOD ALT-145* AST-374* LD(LDH)-609* AlkPhos-1483* TotBili-15.6* [MASKED] 02:01AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 Brief Hospital Course: PATIENT SUMMARY =============== Ms. [MASKED] is a [MASKED] year-old woman with a PMH of newly diagnosed pancreatic cancer and known liver metastases, currently receiving chemotherapy, who presented with fatigue and vomiting, found to have acute anemia (Hg 3.8), admitted to the ICU for close monitoring and resuscitation. She was transfused 3 units in total with recovery of Hg to 8.9. She underwent EGD with epinephrine injection of an area of oozing near a hiatal hernia. She concurrently underwent ERCP with placement of a bare metal stent and a PD stent to relieve her biliary obstruction. Her Xarelto was held throughout the admission given UGIB. The decision regarding restarting it will require further discussion with cardiology. Finally, a family meeting was held with palliative care to discuss prognosis and goals of care (she will ultimately need to decide whether to continue chemotherapy or not). #Acute Blood Loss Anemia Patient had guaiac positive stool in the ED. GI bleed was in the setting of DAPT + xarelto, but no history of prior GIBs, and drinking history in past but never diagnosed with cirrhosis. Hemolysis labs negative. She was placed on IV PPI. She received a total of 3 units pRBCs and 1 unit plasma. GI was consulted and performed EGD during ERCP, which showed GEJ oozing with no obvious lesions and oozing from several erosions in the small intestine with no clear lesion. She was transfused for threshold of Hg <8 given recent MI. #Pancreatic Cancer, Stage IV #Transaminitis #Hyperbilirubinemia #Abdominal Pain / Constipation #Malnutrition Prior to hospitalization, patient had biopsy of liver metastasis revealing adenocarcinoma of pancreaticobiliary origin. She is followed by Dr. [MASKED] at [MASKED]. S/p Fosfirinox x1, which was poorly tolerated. She was switched to [MASKED] on [MASKED]. She had known biliary/pancreatic duct obstruction, and had been planning for ERCP/stent placement on [MASKED] at [MASKED], but this was delayed due to anticoagulation requirement. ERCP was performed on [MASKED] at [MASKED] along with EGD, biliary stents were placed and obstruction was relieved. Her pain was treated with morphine and dilaudid. Nausea was treated with Zofran, prochlorperazine. She continued to receive lorazepam, senna, docusate. Nutrition consult was placed for malnutrition. A 5 day course of Unasyn was started due to concern for cholangitis. Patient had improvement of symptoms after ERCP. Encouraged PO intake as tolerated. #Hx PE #Intracardial clot #Elevated INR Provoked in setting of active malignancy. INR 10 on admission, s/p Vit K with improvement in coagulopathy. Likely contribution of poor PO intake and cholestasis-induced liver injury. No hypoxia or calf tenderness on admission. IVC filter in place. Reported history of intracardiac clot. TTE on [MASKED] with possible thrombus vs tumor at the IVC/RA junction. Prior TEE from [MASKED] showed intracardial clot, consistent with this TTE finding. Given this, she will likely need to continue anticoagulation on discharge. [MASKED] was held on discharge from [MASKED]. Will require conversation to assess risks and benefits of restarting anticoagulation. #Leukocytosis: #Single positive blood culture Patient currently on chemotherapy, last WBC was 6.4 on [MASKED]. Currently without clear localizing cause. Has chronic abdominal pain, which has not changed over past week. Most likely from cholestasis as there was finding of thickened bile prior to relief of biliary obstruction on ERCP. One blood culture from [MASKED] turned positive on the [MASKED] prior to transfer, growing GPCs in pairs and clusters. Patient has been afebrile and clinically improving, therefore suspect contamination. Unasyn continued for anticipated 5d course #[MASKED] Patient with recent diagnosis of metastatic cancer. She has had a difficult time coping with the diagnosis and dealt with a lot of denial. In addition, she lives with her sister who explains that she is having difficulty caring for her at home. Brother is concerned about her home situation. Palliative care and social work were consulted. During an extensive family meeting, several options were laid out: 1) return home with increased [MASKED] services to help offload family members 2) nursing home 3)as her disease progresses, consideration of hospice whether inpatient or outpatient. No unified decision was made. Patient understand the role of palliative care in helping improve her quality of life a bit better and will require very close outpatient follow up once she is discharged. She will additionally need to follow up closely with her oncologist regarding expectations surrounding cancer diagnosis. #CAD s/p MI w PCI Developed STEMI while hospitalized at [MASKED] in [MASKED]. Mild troponin elevation 0.05, flat on re-check, with normal MB. No chest pain. She was continued on aspirin 81, Plavix 75. Metoprolol was held during this hospitalization. #Anxiety: She was continued on Sertraline and Bupropion daily TRANSITIONAL ISSUES ===================== #Biliary obstruction s/p stenting [] Will need repeat ERCP in 2 weeks at [MASKED] for possible PD stent removal [] Unasyn 5d course ([MASKED]) #Hx PE and atrial clot on AC [] Anticoagulation (home Xarelto) was held in the setting of GI bleed, will need to have conversation regarding risks of holding anticoagulation in the setting of intracardial clot vs risk of rebleeding if it is restarted. Patient has known atrial clot discovered on TTE/TEE at [MASKED]. #Palliative Care / Advanced Care Planning [] Recommend inpatient palliative care consult with transition to outpatient pall care. Family was specifically interested in being connected with a specialized social worker to help patient/family cope with diagnosis. [] Will require close follow up with her oncologist Dr. [MASKED] [MASKED] expectations for her prognosis to assist in advanced care planning. [] Patient's family has been struggling to provide adequate care at home (lives with sister, patient wants to be very independent). They will benefit from increased [MASKED] services and discussion of possible placement in SNF. Ultimately hospice will be a good option for patient, particularly if her oncologist reports a poor prognosis. #CAD [] Metoprolol was held on discharge in the setting of low SBPs. Was likely initiated for cardioprotection s/p MI, consider the value of this medication given overall poor prognosis from pancreatic cancer. #Code: full code for now (will require further discussion as disease progresses) #Contact: brother [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS [MASKED] 15 mg PO Q12H 2. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 3. Senna 8.6 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 5. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 6. LORazepam 0.5 mg PO Q6H:PRN anxiety 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 8. Sertraline 100 mg PO DAILY 9. BuPROPion XL (Once Daily) 300 mg PO DAILY 10. Clopidogrel 75 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Rivaroxaban 15 mg PO DAILY 13. Metoprolol Tartrate 12.5 mg PO BID Discharge Medications: 1. Ampicillin-Sulbactam 3 g IV Q6H Duration: 5 Days 2. Pantoprazole 40 mg PO Q12H 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. BuPROPion XL (Once Daily) 300 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 8. LORazepam 0.5 mg PO Q6H:PRN anxiety 9. Morphine SR (MS [MASKED] 15 mg PO Q12H 10. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 11. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 12. Senna 8.6 mg PO DAILY 13. Sertraline 100 mg PO DAILY 14. HELD- Metoprolol Tartrate 12.5 mg PO BID This medication was held. Do not restart Metoprolol Tartrate until your doctor tells you to 15. HELD- Rivaroxaban 15 mg PO DAILY This medication was held. Do not restart Rivaroxaban until your doctor tells you to Discharge Disposition: Extended Care Discharge Diagnosis: metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: It was a pleasure caring for you at [MASKED]! Why did you come to the hospital? You came to the hospital because you felt weak and were noted to have very low blood levels. When this was noticed, you were transferred from [MASKED] to the [MASKED] ICU for intensive care. What did we do for you while you were here? We gave you several units of blood to help increase your blood levels. The gastroenterologists did a procedure and placed stents to help relieve the obstruction in your liver. You felt much better so you were discharged back to [MASKED] so you could be closer to home and with your primary doctors. What should you do when you leave the hospital? You should be sure to follow up with the gastroenterologists. They have recommended that you return for a repeat of the procedure in 2 weeks to make sure that the obstruction continues to be open. You should also follow closely with the palliative care doctors. Followup Instructions: [MASKED]
[]
[ "D62", "Z7901", "I2510", "Z955", "Z7902", "Z87891", "F419" ]
[ "K921: Melena", "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "K831: Obstruction of bile duct", "C250: Malignant neoplasm of head of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "D62: Acute posthemorrhagic anemia", "D684: Acquired coagulation factor deficiency", "K8309: Other cholangitis", "E46: Unspecified protein-calorie malnutrition", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z87891: Personal history of nicotine dependence", "F419: Anxiety disorder, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "D72829: Elevated white blood cell count, unspecified" ]
10,067,195
24,960,457
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Perc chole tube placement ___ ERCP ___ History of Present Illness: ___ with stage IV pancreatic adenocarcinoma, liver mets, PE in ___, acalculous cholecystitis with biliary stent placed at ___ last admission, recent STEMI and PCI, presents as transfer from ___ with 2 2 days of upper abdominal pain different from usual pain and found to have acute acalculous cholecystitis seen on CT scan yesterday evening. Complicated stay at ___ summarized below, admitted initially ___ with GIB and profound anemia On arrival, pt describes pain as having been RUQ under rib for several weeks. Now worsened and moved to epigastrum for about a week. Sharp, constant, worse with deep breaths. Nausea limiting PO intake. No pain related to intake. Intermittent emesis. Having regular BM, last yesterday. No blood. Home pain regimen Oxycontin + dilaudid for breakthrough with some mild nausea associated with these meds. Denies f/c. SOB when exertin self too much but no change recently; known PE. No CP, urinary frequ/pain. Prior records including OSH reviewed and summarized as follows: Panc ca Dx in ___. Care appears to be at ___. Had ERCP here at ___ w/ biliary stent about a month ago; LFTs better since then; is scheduled for ERCP w/ stent re-eval next week. ___ with new PE, and IVC filtedr placement. Recently seen atrial thrombus vs. mass, on xarelto (this was restarted at home about a week ago). Recent MI on aspirin & Plavix (2 stents placed in ___ at ___. Transfer initiated for ___ eval of perc chole tube vs surgical CCY. Pt has expressed high interest in celiac plexus block for her abdominal pain, but unclear what discussion has actually been undertaken, or who has offered this therapy. Admit to ___ on ___. Acute UGIB on arrival with Hb reportedly 3. Multiple blood transfions. Gastric ulcer. Surgery consulted re cholecystits but not considered acceptable risk for anesthesia given MI and DAPT, AC. Oncologist ___ consulted; planned to defer chemo scheduled for this past week pending plan re abdominal pain and aclaculous cholecystitis; subsequent notes imply that no more palliative chemo to be pursued. Cards also consulted for typical CP following her stenting; there was missing info regarding type of stent placed (done at ___. Also notes a right atrial mass that may be thrombus on CT. No echo report is included. IV zosyn was started on day prior to DC though unclear evidence of cholangitis. There was a plan for biliary stent removal around this week (placed at ___. tbili down from 10 to 3.5 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Left ACL repair (___) - Hysterectomy / BSO for uterine fibroids (___) - Pancreatic Adenocarcinoma Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Afebrile and vital signs WNL GENERAL: Alert and in minimal distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. 1+ ___ edema to mid shins RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended. Bowel sounds present. Mild TTP in RUQ, epigastrum. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: VS: 98.6 PO 106/64 75 18 96 2L NC GEN: sleepy, intermittently uncomfortabel Eyes: mild scleral icterus, non-injected HEENT: MM dry, grossly nl OP CV: RRR nl S1/S2 no g/r/m CHEST: crackles at bases, some rhonchi in upper lung fields Abd: soft, mild ttp throughout without rebound. GU: No suprapubic fullness or tenderness to palpation Ext: WWP. TEDS in place with thin legs, 2+ pitting edema at hips SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: mildly anxious Pertinent Results: OSH LABS: last wbc 12, hb 7.4 (reported as low as 3), plt 212 Na 138, K 3.6 bcb 24, Cr 0.6, alb 2.5, tbili 3.6, direct 2.5, AP 801, AST 44, ALT 20, INR 1.7, trop neg (last on ___, ADMISSION LABS: ___ 05:17AM BLOOD WBC-11.4* RBC-2.35* Hgb-7.1* Hct-22.8* MCV-97 MCH-30.2 MCHC-31.1* RDW-19.9* RDWSD-66.7* Plt ___ ___ 05:17AM BLOOD ___ ___ 05:17AM BLOOD Glucose-105* UreaN-10 Creat-0.4 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-13 ___ 05:17AM BLOOD ALT-19 AST-37 LD(LDH)-427* AlkPhos-779* TotBili-3.6* ___ 05:17AM BLOOD Albumin-2.3* Calcium-7.6* Phos-3.5 Mg-1.8 IMAGING: - KUB ___: Pancreatic duct stent in appropriate positioning - TTE ___: Suspicion for malignant thrombotic process with masses on the mitral valve (marantic endocarditis) not seen on prior study from less than one month ago, possible thrombus in the coronary sinus (likley same mass seen on eustachian valve but could be two masses), recent pulmonary embolism, and recent STEMI in the context of underlying malignant pancreatic cancer. Moderate pulmoanry hypertension. TEE recommended. - LENIS (___): 1. Superficial occlusive thrombus in the right greater saphenous vein within 1cm of its junction with the common femoral vein. 2. No deep venous thrombosis in the right or left lower extremity veins. - CTV (IVCF study) (___): 1. Appropriately positioned IVC filter. No evidence of central venous thrombosis. 2. Redemonstrated pancreatic head mass and extensive hepatic metastasis. 3. Interval placement of a cholecystostomy tube, appropriately position. 4. Stable small volume ascites in the pelvis and anasarca. 5. Stable small right pleural effusion with adjacent atelectasis. -Liver US ___: 1. Gallbladder similar in appearance compared to most recent CT with intraluminal sludge and partially visualized cholecystostomy tube. Tube traverses into the gallbladder, but tip of the tube is not well visualized. There is no new dilation of the gallbladder to suggest any obstruction. No adjacent collection. 2. Unchanged hepatic metastases with expected pneumobilia. No biliary dilation. 3. Unchanged dilation of the main pancreatic duct to 6 mm in size. -CT Abd/pelvis ___: 1. No significant change in pancreatic head mass or extensive hepatic metastatic disease. 2. CBD stent, pancreatic duct stent, and percutaneous cholecystostomy tube appears appropriately position. 3. Stable small volume ascites and anasarca. 4. New, small splenic infarct. 5. Slight interval increase in size of small right greater than left pleural effusions. -ERCP ___ with removal of PD stent and metal biliary stent. Cholangiogram with distal CBD stricture upstream dilation. plastic biliar stent placed. Suspect retroperitoneal extravasation of contrast during procedure, likely through necrotic tumor. Tumor ingrowth noted into the third portion of the duodenum -CT chest ___. Bilateral upper lobe predominant multifocal ground-glass opacities can be concerning for the mild-to-moderate pulmonary edema. Superimposed infection is not excluded in the appropriate clinical setting. 2. Linear areas of filling defects in multiple bilateral subsegmental branches are compatible with chronic appearing known pulmonary emboli. Discharge labs: ============== ___ 06:50AM BLOOD WBC-31.7* RBC-2.82* Hgb-8.4* Hct-26.9* MCV-95 MCH-29.8 MCHC-31.2* RDW-22.9* RDWSD-72.8* Plt ___ ___ 06:50AM BLOOD Glucose-60* UreaN-11 Creat-0.8 Na-134* K-4.2 Cl-96 HCO3-25 AnGap-13 ___ 06:50AM BLOOD ALT-13 AST-47* LD(LDH)-993* AlkPhos-829* TotBili-3.4* DirBili-2.5* IndBili-0.9 ___ 06:50AM BLOOD Calcium-7.3* Phos-2.4* Mg-1.8 ___ 06:50AM BLOOD Hapto-140 Micro: ======== Bile culture ___: GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final ___: ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. Cefepime MIC <=2 MCG/ML . Cefepime test result performed by Microscan. ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. SECOND MORPHOLOGY. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | ENTEROBACTER CLOACAE COMPLEX | | CEFEPIME-------------- S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- 8 R <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ 4 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- 16 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Final ___: CLOSTRIDIUM PERFRINGENS. MODERATE GROWTH. Brief Hospital Course: ___ is a ___ year old woman with a history of metastatic pancreatic adenocarcinoma with liver metastaasis, recent PE (___) and recent STEMI (___), prior ERCP metal PD and plastic stenting ___ ___. She has been hospitalized continuously at ___ for 3 weeks with originally admission to ___ in mid ___, with transfer to BI late in the ___ for GI bleeding and ERCP/stent placement. She was subsequently transferred back to ___ on ___ where she remained hospitalized until she was returned to ___ for management of acalculous cholecystitis. Her hospital course was notable for diagnosis of marantic endocarditis and acute right heart failure with anasarca and marked leukocytosis. After family meeting held ___, the decision was made to transition to ___ focused care with transfer to ___ for hospice care. #Goals of care: Ms. ___ was newly diagnosed with metastatic pancreatic cancer in ___ of this year with complications including hypercoaguability manifesting in bilateral PEs, marantic endocarditis, STEMI and superficial venous thromboembolism as well as acalculous cholecystitis, GI bleeding and anasarca. She has been in and out of the hospital since diagnosis with prolonged hospitalization on this presentation. She has been supported by her family (5 siblings) throughout her journey. On ___, we met at the bedside with Ms. ___, her sister and 3 of her brothers as well as the palliative care team and myself (hospitalist) to discuss her care and her goals moving forward. ___ was clear that she is at the end of life and understands her diagnosis is terminal. Her family expressed a desire to have her closer to home and to focus on comfort and ___ agreed that this was her goal, to not be in a hospital setting. As such, the decision was made to transition toward a focus on comfort with discharge to hospice at ___. As I discussed with Ms. ___, we can continue oral abx for her acalculous cholecystitis and anticoagulation for her clots which can be stopped at whatever point she desires. Her family and the patient were comfortable with this plan. # Acalculous Cholecystitis: Patient admitted with severe RUQ abdominal pain and CT imaging concerning for acalculous cholecystitis. She was managed with IV narcotics and unasyn antibiotic therapy. Hepatobiliary surgery felt patient was not a surgical candidate, and ERCP felt intraluminal options were limited, so patient proceed with high risk PTC (as triple therapy could not safely be held, see below). Post-operatively, her abdominal pain symptoms initially improved dramataically, although she did experience transient drain site pain. Bile cultures grew Clostrium perfringens and GNRs. She was initially treated with broad abx which were narrowed to cipro/augmentin at discharge to continue at least through ___ or based on patient comfort. Drain will remain in place indefinitely for ongoing drainage of her gallbladder. # Marantic Endocarditis: # Pulmonary Embolism # Intracardiac Mass: # Right Superficial Venous Thrombosis: Patient's pre-hospital course had been marked by a constellation of multiple thrombobic events (STEMI, PE, DVT). TTE on admission (originally ordered to evaluate for persistence of previously seen intracardiac mass) notable for the development of extensive mitral valve thrombosis, concerning for marantic endocarditis. Platelets and fibrinogen were wnl, arguing against malignancy related chronic DIC. Vascular cardiology recommended anticoagulation be changed to lovenox. LENIS notable for superficial thrombosis. Serial TTE also noted increasing PASP, concerning for ongoing VTE/PE events causing CHF symptoms (below). Ms. ___ was discharged on lovenox once daily (1.5mg/kg daily). # Acute Right Sided Congestive Heart Failure # Acute hypoxemic respiratory failure # Anasarca: Patient noted to have ___ edema on admission that appeared to worsen during her course likely related to fluids received while NPO, low albumin and elevated PASP on serial TTE (increased from 27-->52 this admission) suggesting ongoing VTE/CTEPH and subsequent right heart failure. She also had new hypoxia felt to be due to fluid though could be component of atypical infection based on CT read (afebrile). She was diuresed with some improvement. # Leukocytosis: Patient developed worsening leukocytosis after placement of perc chole tube. She underwent ERCP without e/o cholangitis though with evidence of necrotic tumor invading into duodenum. CT abdomen without source of infection. CT chest with likely pulmonary edema though cannot rule out infection. Cdiff sent and pending. ID consulted and felt that there was a possibility of suprainfection of one of her necrotic mets however given her high risk of bleeding and goals of care, further investigation of infection of her metastates was not deem in her goals of care. # Metastatic Pancreatic Cancer: With liver metastasis found to have new splenic metastases while here. ___ oncologist: ___ ___ was contacted and case discussed. She reported that patient was s/p folfirinox x1 cycle and then trialed briefly on gemcitabine however at this time is no longer a candidate for treatment. Palliative care was consulted and assisted with ongoing ___ conversation. As above, patient is being discharged to hospice. # Coronary Artery Disease # Recent Inferior STEMI: Patient has PCI with BMS to RCA > 1 month prior to admission, vascular cardiology recommended continuing clopidogrel, but stopping aspirin. # Anemia # GI Bleeding: EGD (___) ___ with oozing from superficial erosions in hiatal hernia and duodenum. Pt reports no bleeding since last transfer. ___ Hb with gradual downtrend from 8.8 since ___. She received 1u pRBC on ___ with appropriate bump in hgb and no e/o bleeding on exam. # Depression: Continued home buproprion and sertraline. # GERD: Continued pantoprazole Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 6. LORazepam 0.5 mg PO Q6H:PRN anxiety 7. Morphine SR (MS ___ 60 mg PO Q12H 8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 9. Senna 8.6 mg PO DAILY 10. Sertraline 150 mg PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Metoprolol Tartrate 12.5 mg PO BID 13. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 14. Rivaroxaban 20 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Enoxaparin Sodium 110 mg SC QAM 4. Fentanyl Patch 37 mcg/h TD Q72H 5. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 6. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 7. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN BREAKTHROUGH PAIN 8. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: canceling other order 9. Polyethylene Glycol 17 g PO DAILY 10. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate 13. Senna 8.6 mg PO BID 14. BuPROPion XL (Once Daily) 300 mg PO DAILY 15. Clopidogrel 75 mg PO DAILY 16. LORazepam 0.5 mg PO Q6H:PRN anxiety 17. Pantoprazole 40 mg PO Q12H 18. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 19. Sertraline 150 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acalculous cholecystitis Marantic endocarditis Pulmonary embolism Anasarca Leukocytosis Acute on chronic anemia Metastatic pancreatic cancer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for management of an infection in your gallbladder. You had a tube placed in your gallbladder to drain your infection and were treated with antibiotics. Due to progression of your pancreatic cancer, you have decided to focus on your comfort. You are being transferred to ___ house which is a hospice house that specializes in managing symptoms related to advanced cancer. They will help manage your nausea, pain and confusion. You will continue to take blood thinners to prevent progression of your clots and antibiotics for your infection. You can stop these at any time if it becomes too difficult to take medications or if you decide you do not want additional injections. It was a pleasure taking care of you. We wish you all the best. Your ___ Care Team Followup Instructions: ___
[ "K810", "K831", "J9601", "C259", "C787", "C7889", "I38", "Z515", "I50811", "I513", "I2510", "K219", "D649", "Z66", "K449", "F329", "I252", "Z955", "Z87891", "Z86711", "Z7901" ]
Allergies: oxycodone Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Perc chole tube placement [MASKED] ERCP [MASKED] History of Present Illness: [MASKED] with stage IV pancreatic adenocarcinoma, liver mets, PE in [MASKED], acalculous cholecystitis with biliary stent placed at [MASKED] last admission, recent STEMI and PCI, presents as transfer from [MASKED] with 2 2 days of upper abdominal pain different from usual pain and found to have acute acalculous cholecystitis seen on CT scan yesterday evening. Complicated stay at [MASKED] summarized below, admitted initially [MASKED] with GIB and profound anemia On arrival, pt describes pain as having been RUQ under rib for several weeks. Now worsened and moved to epigastrum for about a week. Sharp, constant, worse with deep breaths. Nausea limiting PO intake. No pain related to intake. Intermittent emesis. Having regular BM, last yesterday. No blood. Home pain regimen Oxycontin + dilaudid for breakthrough with some mild nausea associated with these meds. Denies f/c. SOB when exertin self too much but no change recently; known PE. No CP, urinary frequ/pain. Prior records including OSH reviewed and summarized as follows: Panc ca Dx in [MASKED]. Care appears to be at [MASKED]. Had ERCP here at [MASKED] w/ biliary stent about a month ago; LFTs better since then; is scheduled for ERCP w/ stent re-eval next week. [MASKED] with new PE, and IVC filtedr placement. Recently seen atrial thrombus vs. mass, on xarelto (this was restarted at home about a week ago). Recent MI on aspirin & Plavix (2 stents placed in [MASKED] at [MASKED]. Transfer initiated for [MASKED] eval of perc chole tube vs surgical CCY. Pt has expressed high interest in celiac plexus block for her abdominal pain, but unclear what discussion has actually been undertaken, or who has offered this therapy. Admit to [MASKED] on [MASKED]. Acute UGIB on arrival with Hb reportedly 3. Multiple blood transfions. Gastric ulcer. Surgery consulted re cholecystits but not considered acceptable risk for anesthesia given MI and DAPT, AC. Oncologist [MASKED] consulted; planned to defer chemo scheduled for this past week pending plan re abdominal pain and aclaculous cholecystitis; subsequent notes imply that no more palliative chemo to be pursued. Cards also consulted for typical CP following her stenting; there was missing info regarding type of stent placed (done at [MASKED]. Also notes a right atrial mass that may be thrombus on CT. No echo report is included. IV zosyn was started on day prior to DC though unclear evidence of cholangitis. There was a plan for biliary stent removal around this week (placed at [MASKED]. tbili down from 10 to 3.5 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Left ACL repair ([MASKED]) - Hysterectomy / BSO for uterine fibroids ([MASKED]) - Pancreatic Adenocarcinoma Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Afebrile and vital signs WNL GENERAL: Alert and in minimal distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. 1+ [MASKED] edema to mid shins RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended. Bowel sounds present. Mild TTP in RUQ, epigastrum. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: VS: 98.6 PO 106/64 75 18 96 2L NC GEN: sleepy, intermittently uncomfortabel Eyes: mild scleral icterus, non-injected HEENT: MM dry, grossly nl OP CV: RRR nl S1/S2 no g/r/m CHEST: crackles at bases, some rhonchi in upper lung fields Abd: soft, mild ttp throughout without rebound. GU: No suprapubic fullness or tenderness to palpation Ext: WWP. TEDS in place with thin legs, 2+ pitting edema at hips SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: mildly anxious Pertinent Results: OSH LABS: last wbc 12, hb 7.4 (reported as low as 3), plt 212 Na 138, K 3.6 bcb 24, Cr 0.6, alb 2.5, tbili 3.6, direct 2.5, AP 801, AST 44, ALT 20, INR 1.7, trop neg (last on [MASKED], ADMISSION LABS: [MASKED] 05:17AM BLOOD WBC-11.4* RBC-2.35* Hgb-7.1* Hct-22.8* MCV-97 MCH-30.2 MCHC-31.1* RDW-19.9* RDWSD-66.7* Plt [MASKED] [MASKED] 05:17AM BLOOD [MASKED] [MASKED] 05:17AM BLOOD Glucose-105* UreaN-10 Creat-0.4 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-13 [MASKED] 05:17AM BLOOD ALT-19 AST-37 LD(LDH)-427* AlkPhos-779* TotBili-3.6* [MASKED] 05:17AM BLOOD Albumin-2.3* Calcium-7.6* Phos-3.5 Mg-1.8 IMAGING: - KUB [MASKED]: Pancreatic duct stent in appropriate positioning - TTE [MASKED]: Suspicion for malignant thrombotic process with masses on the mitral valve (marantic endocarditis) not seen on prior study from less than one month ago, possible thrombus in the coronary sinus (likley same mass seen on eustachian valve but could be two masses), recent pulmonary embolism, and recent STEMI in the context of underlying malignant pancreatic cancer. Moderate pulmoanry hypertension. TEE recommended. - LENIS ([MASKED]): 1. Superficial occlusive thrombus in the right greater saphenous vein within 1cm of its junction with the common femoral vein. 2. No deep venous thrombosis in the right or left lower extremity veins. - CTV (IVCF study) ([MASKED]): 1. Appropriately positioned IVC filter. No evidence of central venous thrombosis. 2. Redemonstrated pancreatic head mass and extensive hepatic metastasis. 3. Interval placement of a cholecystostomy tube, appropriately position. 4. Stable small volume ascites in the pelvis and anasarca. 5. Stable small right pleural effusion with adjacent atelectasis. -Liver US [MASKED]: 1. Gallbladder similar in appearance compared to most recent CT with intraluminal sludge and partially visualized cholecystostomy tube. Tube traverses into the gallbladder, but tip of the tube is not well visualized. There is no new dilation of the gallbladder to suggest any obstruction. No adjacent collection. 2. Unchanged hepatic metastases with expected pneumobilia. No biliary dilation. 3. Unchanged dilation of the main pancreatic duct to 6 mm in size. -CT Abd/pelvis [MASKED]: 1. No significant change in pancreatic head mass or extensive hepatic metastatic disease. 2. CBD stent, pancreatic duct stent, and percutaneous cholecystostomy tube appears appropriately position. 3. Stable small volume ascites and anasarca. 4. New, small splenic infarct. 5. Slight interval increase in size of small right greater than left pleural effusions. -ERCP [MASKED] with removal of PD stent and metal biliary stent. Cholangiogram with distal CBD stricture upstream dilation. plastic biliar stent placed. Suspect retroperitoneal extravasation of contrast during procedure, likely through necrotic tumor. Tumor ingrowth noted into the third portion of the duodenum -CT chest [MASKED]. Bilateral upper lobe predominant multifocal ground-glass opacities can be concerning for the mild-to-moderate pulmonary edema. Superimposed infection is not excluded in the appropriate clinical setting. 2. Linear areas of filling defects in multiple bilateral subsegmental branches are compatible with chronic appearing known pulmonary emboli. Discharge labs: ============== [MASKED] 06:50AM BLOOD WBC-31.7* RBC-2.82* Hgb-8.4* Hct-26.9* MCV-95 MCH-29.8 MCHC-31.2* RDW-22.9* RDWSD-72.8* Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-60* UreaN-11 Creat-0.8 Na-134* K-4.2 Cl-96 HCO3-25 AnGap-13 [MASKED] 06:50AM BLOOD ALT-13 AST-47* LD(LDH)-993* AlkPhos-829* TotBili-3.4* DirBili-2.5* IndBili-0.9 [MASKED] 06:50AM BLOOD Calcium-7.3* Phos-2.4* Mg-1.8 [MASKED] 06:50AM BLOOD Hapto-140 Micro: ======== Bile culture [MASKED]: GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [MASKED]: ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. Cefepime MIC <=2 MCG/ML . Cefepime test result performed by Microscan. ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. SECOND MORPHOLOGY. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROBACTER CLOACAE COMPLEX | ENTEROBACTER CLOACAE COMPLEX | | CEFEPIME-------------- S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- 8 R <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ 4 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- 16 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Final [MASKED]: CLOSTRIDIUM PERFRINGENS. MODERATE GROWTH. Brief Hospital Course: [MASKED] is a [MASKED] year old woman with a history of metastatic pancreatic adenocarcinoma with liver metastaasis, recent PE ([MASKED]) and recent STEMI ([MASKED]), prior ERCP metal PD and plastic stenting [MASKED] [MASKED]. She has been hospitalized continuously at [MASKED] for 3 weeks with originally admission to [MASKED] in mid [MASKED], with transfer to BI late in the [MASKED] for GI bleeding and ERCP/stent placement. She was subsequently transferred back to [MASKED] on [MASKED] where she remained hospitalized until she was returned to [MASKED] for management of acalculous cholecystitis. Her hospital course was notable for diagnosis of marantic endocarditis and acute right heart failure with anasarca and marked leukocytosis. After family meeting held [MASKED], the decision was made to transition to [MASKED] focused care with transfer to [MASKED] for hospice care. #Goals of care: Ms. [MASKED] was newly diagnosed with metastatic pancreatic cancer in [MASKED] of this year with complications including hypercoaguability manifesting in bilateral PEs, marantic endocarditis, STEMI and superficial venous thromboembolism as well as acalculous cholecystitis, GI bleeding and anasarca. She has been in and out of the hospital since diagnosis with prolonged hospitalization on this presentation. She has been supported by her family (5 siblings) throughout her journey. On [MASKED], we met at the bedside with Ms. [MASKED], her sister and 3 of her brothers as well as the palliative care team and myself (hospitalist) to discuss her care and her goals moving forward. [MASKED] was clear that she is at the end of life and understands her diagnosis is terminal. Her family expressed a desire to have her closer to home and to focus on comfort and [MASKED] agreed that this was her goal, to not be in a hospital setting. As such, the decision was made to transition toward a focus on comfort with discharge to hospice at [MASKED]. As I discussed with Ms. [MASKED], we can continue oral abx for her acalculous cholecystitis and anticoagulation for her clots which can be stopped at whatever point she desires. Her family and the patient were comfortable with this plan. # Acalculous Cholecystitis: Patient admitted with severe RUQ abdominal pain and CT imaging concerning for acalculous cholecystitis. She was managed with IV narcotics and unasyn antibiotic therapy. Hepatobiliary surgery felt patient was not a surgical candidate, and ERCP felt intraluminal options were limited, so patient proceed with high risk PTC (as triple therapy could not safely be held, see below). Post-operatively, her abdominal pain symptoms initially improved dramataically, although she did experience transient drain site pain. Bile cultures grew Clostrium perfringens and GNRs. She was initially treated with broad abx which were narrowed to cipro/augmentin at discharge to continue at least through [MASKED] or based on patient comfort. Drain will remain in place indefinitely for ongoing drainage of her gallbladder. # Marantic Endocarditis: # Pulmonary Embolism # Intracardiac Mass: # Right Superficial Venous Thrombosis: Patient's pre-hospital course had been marked by a constellation of multiple thrombobic events (STEMI, PE, DVT). TTE on admission (originally ordered to evaluate for persistence of previously seen intracardiac mass) notable for the development of extensive mitral valve thrombosis, concerning for marantic endocarditis. Platelets and fibrinogen were wnl, arguing against malignancy related chronic DIC. Vascular cardiology recommended anticoagulation be changed to lovenox. LENIS notable for superficial thrombosis. Serial TTE also noted increasing PASP, concerning for ongoing VTE/PE events causing CHF symptoms (below). Ms. [MASKED] was discharged on lovenox once daily (1.5mg/kg daily). # Acute Right Sided Congestive Heart Failure # Acute hypoxemic respiratory failure # Anasarca: Patient noted to have [MASKED] edema on admission that appeared to worsen during her course likely related to fluids received while NPO, low albumin and elevated PASP on serial TTE (increased from 27-->52 this admission) suggesting ongoing VTE/CTEPH and subsequent right heart failure. She also had new hypoxia felt to be due to fluid though could be component of atypical infection based on CT read (afebrile). She was diuresed with some improvement. # Leukocytosis: Patient developed worsening leukocytosis after placement of perc chole tube. She underwent ERCP without e/o cholangitis though with evidence of necrotic tumor invading into duodenum. CT abdomen without source of infection. CT chest with likely pulmonary edema though cannot rule out infection. Cdiff sent and pending. ID consulted and felt that there was a possibility of suprainfection of one of her necrotic mets however given her high risk of bleeding and goals of care, further investigation of infection of her metastates was not deem in her goals of care. # Metastatic Pancreatic Cancer: With liver metastasis found to have new splenic metastases while here. [MASKED] oncologist: [MASKED] [MASKED] was contacted and case discussed. She reported that patient was s/p folfirinox x1 cycle and then trialed briefly on gemcitabine however at this time is no longer a candidate for treatment. Palliative care was consulted and assisted with ongoing [MASKED] conversation. As above, patient is being discharged to hospice. # Coronary Artery Disease # Recent Inferior STEMI: Patient has PCI with BMS to RCA > 1 month prior to admission, vascular cardiology recommended continuing clopidogrel, but stopping aspirin. # Anemia # GI Bleeding: EGD ([MASKED]) [MASKED] with oozing from superficial erosions in hiatal hernia and duodenum. Pt reports no bleeding since last transfer. [MASKED] Hb with gradual downtrend from 8.8 since [MASKED]. She received 1u pRBC on [MASKED] with appropriate bump in hgb and no e/o bleeding on exam. # Depression: Continued home buproprion and sertraline. # GERD: Continued pantoprazole Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 6. LORazepam 0.5 mg PO Q6H:PRN anxiety 7. Morphine SR (MS [MASKED] 60 mg PO Q12H 8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 9. Senna 8.6 mg PO DAILY 10. Sertraline 150 mg PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Metoprolol Tartrate 12.5 mg PO BID 13. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 14. Rivaroxaban 20 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Enoxaparin Sodium 110 mg SC QAM 4. Fentanyl Patch 37 mcg/h TD Q72H 5. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 6. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 7. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN BREAKTHROUGH PAIN 8. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: canceling other order 9. Polyethylene Glycol 17 g PO DAILY 10. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. HYDROmorphone (Dilaudid) [MASKED] mg PO Q3H:PRN Pain - Moderate 13. Senna 8.6 mg PO BID 14. BuPROPion XL (Once Daily) 300 mg PO DAILY 15. Clopidogrel 75 mg PO DAILY 16. LORazepam 0.5 mg PO Q6H:PRN anxiety 17. Pantoprazole 40 mg PO Q12H 18. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 19. Sertraline 150 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acalculous cholecystitis Marantic endocarditis Pulmonary embolism Anasarca Leukocytosis Acute on chronic anemia Metastatic pancreatic cancer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for management of an infection in your gallbladder. You had a tube placed in your gallbladder to drain your infection and were treated with antibiotics. Due to progression of your pancreatic cancer, you have decided to focus on your comfort. You are being transferred to [MASKED] house which is a hospice house that specializes in managing symptoms related to advanced cancer. They will help manage your nausea, pain and confusion. You will continue to take blood thinners to prevent progression of your clots and antibiotics for your infection. You can stop these at any time if it becomes too difficult to take medications or if you decide you do not want additional injections. It was a pleasure taking care of you. We wish you all the best. Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "J9601", "Z515", "I2510", "K219", "D649", "Z66", "F329", "I252", "Z955", "Z87891", "Z7901" ]
[ "K810: Acute cholecystitis", "K831: Obstruction of bile duct", "J9601: Acute respiratory failure with hypoxia", "C259: Malignant neoplasm of pancreas, unspecified", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7889: Secondary malignant neoplasm of other digestive organs", "I38: Endocarditis, valve unspecified", "Z515: Encounter for palliative care", "I50811: Acute right heart failure", "I513: Intracardiac thrombosis, not elsewhere classified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "Z66: Do not resuscitate", "K449: Diaphragmatic hernia without obstruction or gangrene", "F329: Major depressive disorder, single episode, unspecified", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants" ]
10,067,306
20,866,745
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: tramadol / Augmentin Attending: ___. Chief Complaint: Stage I(T2N0M0) rectal ca Major Surgical or Invasive Procedure: Abdominoperineal resection, peristomal mesh, posterior vaginectomy, partial, ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, placement of cyberknife feducials, Bilateral V-Y Fasciocutaneous Flap Closure of APR Defect with Surgimend Mesh Placement for soft tissue reinforcement History of Present Illness: ___ woman with radiation and surgery for vulvar cancer ___ years ago with significant radiation damage to perineum presented for evaluation of? Low rectal polyp found on screening colonoscopy Digital exam was difficult in the office but showed irregularity at the level of sphincter and just above extended as ulceration to anoderm directly overlaying anal sphincters Surgical exam under anesthesia was performed low rectal mass with ulceration extending to anoderm was identified and biopsied Pathological slides were reviewed and showed adenocarcinoma with mucinous features MSI stable. Biopsy from perineal radiation damage field shows radiation changes although early angiosarcoma cannot be excluded CT torso was performed and reviewed and showed no evidence of metastatic disease MRI was reviewed and showed T2 low rectal cancer Initial stage is T2N0M0 - I Multidisciplinary rectal cancer tumor board recommends proceeding with abdominoperineal resection and flap closure of the perineum with referral for possible adjuvant chemotherapy after surgery Past Medical History: vulvar cancer, asthma Family History: non contributory Physical Exam: on discharge; ======================================== Physical exam: Vitals: ___ 0748 Temp: 98.4 PO BP: 136/76 HR: 80 RR: 18 O2 sat: 95% O2 delivery: RA General: AxOx3. Appears well HEENT: Eyes anicteric. PEERLA. EOMI. Mucus membranes appear moist Chest: Symmetric. CTAB. No crackles. No DTP Cards: RRR. Nl S1/S2. No M/R/G. Abdomen: Slightly distended, appropriately tender, no R/G. Incision CDI s/p prevena wound vac(now removed). Abdominal JP, flap JPx2, and vaginal JP with ss output. Neuro: Moving all extremities equally. Sensation grossly intact. ___ strength UE and ___. Pertinent Results: ___ 05:35AM BLOOD WBC-8.6 RBC-3.48* Hgb-9.5* Hct-29.8* MCV-86 MCH-27.3 MCHC-31.9* RDW-15.1 RDWSD-46.5* Plt ___ ___ 05:35AM BLOOD Plt ___ ___ 05:35AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-140 K-4.0 Cl-107 HCO3-21* AnGap-12 ___ 05:35AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.2 EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ w prior vulvar cancer s/p vulvectomy and chemorad now w Stage I(T2N0M0) rectal ca s/p open APR with colostomy, TAH/BSO and bilateral ___ fasciocutaneous flaps, now with loss of bowel function, n/v, and leukocytosis// Is there an anastomotic leak or an abscess?PO AND IV CONTRAST PLEASE!!!!! TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was administered. IV contrast: 130ml Omnipaque DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 6.1 s, 0.2 cm; CTDIvol = 104.6 mGy (Body) DLP = 20.9 mGy-cm. 3) Spiral Acquisition 7.8 s, 50.4 cm; CTDIvol = 19.9 mGy (Body) DLP = 990.5 mGy-cm. Total DLP (Body) = 1,013 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is minimal dependent atelectasis at the lung bases. ABDOMEN: GENERAL: Trace free fluid is noted in the presacral space. Tiny locules of free air within the left inguinal region (5:70) are likely postsurgical. A percutaneous surgical drain placed from the right anterior abdominal wall terminates in the pelvis. A second drain placed along the left transgluteal approach terminates in the perineum. No drainable fluid collections seen in the abdomen or pelvis. HEPATOBILIARY: The hepatic parenchyma demonstrates homogeneous attenuation with no focal lesions. No intrahepatic biliary ductal dilation. The portal vein and its branches are patent. The gallbladder is surgically absent. PANCREAS: The pancreatic parenchyma enhances homogeneously without main duct dilation. SPLEEN: No splenomegaly or focal splenic lesions. ADRENALS: No adrenal nodules. URINARY: There are likely peripelvic cysts in the left kidney, however given the lack of a delayed exam, presence of underlying hydronephrosis cannot be completely excluded, a dedicated renal ultrasound is recommended. No right-sided hydronephrosis. No solid enhancing renal masses or renal calculi seen. Likely left renal superior pole cysts. GASTROINTESTINAL: Orally ingested contrast is seen opacifying nonobstructed loops of small bowel. There is no extraluminal contrast to suggest presence of a leak. A left lower quadrant colostomy appears intact. LYMPH NODES: There are no enlarged lymph nodes in the abdomen or pelvis.. VASCULAR: There is a moderate amount of calcified atherosclerotic plaque within the abdominal aorta, without aneurysmal dilation. PELVIS: The bladder is decompressed by a Foley catheter. The uterus and adnexae are surgically absent. Trace free fluid in the presacral space is likely postsurgical. No large drainable fluid collection.. Linear hyperdense material in the pelvis (07:30) is compatible with postsurgical material. BONES AND SOFT TISSUES: A fiducial marker is seen in the right perineum. Subacute fractures involving the right inferior and superior pubic rami noted. Degenerative changes of both sacroiliac joints seen. No worrisome osseous lesions identified. Surgical staples project over the midline pelvic wall. Mild stranding of subcutaneous fat within the anterior pelvic wall, is postsurgical. IMPRESSION: 1. There is no leak of orally ingested contrast through the small bowel loops to suggest presence of bowel perforation or leak. No drainable fluid collections identified. A left lower quadrant colostomy without obstruction noted. The colon is not opacified with orally ingested contrast, however is appropriately distended with fluid. No bowel obstruction. 2. Postsurgical changes in the pelvis in the form of trace free pelvic soft tissue stranding and fluid; tiny locules of air in the left inguinal region; surgical drains noted. Brief Hospital Course: Mr/Ms. ___ presented to ___ holding at ___ on ___ for a APR, post vaginectomy, TAH/BSO, ___ flap. He/She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was controlled with assistance from the ___ service with IV pain medication and an epidural which was transitioned to oral oxycodone and Tylenol once the patient was tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. Had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO after the procedure. She had a post operative ileus and emesis with placement of an NGT for decompression. She began to pass flatus and stool from her ostomy and was started on a bowel regimen. Her NGT was removed and diet was advanced from clear liquids to a regular diet with good tolerability. The patient was tolerating a regular diet at the time of discharge. Patient's intake and output were closely monitored GU: The patient had a Foley catheter that was removed prior to discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient was closely monitored for signs and symptoms of infection and fever. She did have an initial post operative leukocytosis which resolved and remained stable prior to discharge. Heme: The patient had blood levels checked daily during their hospital course to monitor for signs of bleeding. The patient received subcutaneous heparin and ___ dyne boots were used during this stay, she was encouraged to get up and ambulate as early as possible. The patient is being discharged on a prophylactic dose of Lovenox for 30 days post operatively. On POD 10, the patient was discharged to Rehab. At discharge, she was tolerating a regular diet, passing gas and stool from her ostomy, voiding, and ambulating with assistance. She will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [x] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [ ] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 2. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr prn Disp #*120 Tablet Refills:*0 2. Enoxaparin Sodium 40 mg SC Q24H RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*23 Syringe Refills:*0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr prn Disp #*10 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gram by mouth daily Refills:*0 5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 6. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ w prior vulvar cancer s/p vulvectomy and chemorad now w Stage I(T2N0M0) rectal ca s/p open APR with colostomy, TAH/BSO and bilateral ___ fasciocutaneous flaps 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: ___ were admitted to the hospital after an open Ano Peroneal Resection for surgical management of your rectal cancer. ___ also had a TAH/BSO and bilateral fasciocutanous flaps. ___ have recovered from this procedure well and ___ are now ready to return home. Samples of tissue were taken and has been sent to the pathology department. ___ will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact ___ regarding these results they will contact ___ before this time. ___ have a new colostomy. It is important to monitor the output from this stoma. If ___ notice that ___ have not had any stool from your stoma in ___ days, please call the office. Please watch the appearance of the stoma (intestine that protrudes outside of your abdomen), it should be beefy red/pink; if ___ notice that the stoma is turning darker blue or purple please call the office or go to the emergency room. The stoma may ooze small amounts of blood at times when touched but this will improve over time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for any bulging or signs of infection. Please care for the ostomy as ___ have been instructed by the ostomy nurses. ___ will have a visiting nurse at home for the next few weeks to help monitor your ostomy until ___ are comfortable caring for it on your own. If ___ have any of the following symptoms please call the office at ___: fever greater than 101.5 increasing abdominal distension increasing abdominal pain nausea/vomiting inability to tolerate food or liquids prolonged loose stool extended constipation inability to urinate Incisions: ___ have a long vertical surgical incisions on your abdomen. It is important that ___ monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. ___ may shower; pat the incisions dry with a towel, do not rub. If ___ have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain It is expected that ___ will have pain after surgery, this will gradually improve over the first week or so ___ are home. ___ should continue to take 2 Extra Strength Tylenol (___) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. ___ may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days, please take Advil with food. If these medications are not controlling your pain to a point where ___ can ambulate and perform minor tasks, ___ should take a dose of the narcotic pain medication tramadol. Please do not take sedating medications or drink alcohol while taking the narcotic pain medication. Do not drive while taking narcotic medications. ___ will be going home with your JP (surgical) drain, which will be removed at your post-op visit. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently and record output. ___ may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Activity ___ may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear ___ for heavier exercise. In the meantime, ___ may climb stairs, and go outside and walk. Please avoid traveling long distances until ___ speak with your surgical team at your post-op visit. Thank ___ for allowing us to participate in your care, we wish ___ all the best! Followup Instructions: ___
[ "C20", "K567", "J45909", "N183", "E669", "Z6835", "Z8589" ]
Allergies: tramadol / Augmentin Chief Complaint: Stage I(T2N0M0) rectal ca Major Surgical or Invasive Procedure: Abdominoperineal resection, peristomal mesh, posterior vaginectomy, partial, ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, placement of cyberknife feducials, Bilateral V-Y Fasciocutaneous Flap Closure of APR Defect with Surgimend Mesh Placement for soft tissue reinforcement History of Present Illness: [MASKED] woman with radiation and surgery for vulvar cancer [MASKED] years ago with significant radiation damage to perineum presented for evaluation of? Low rectal polyp found on screening colonoscopy Digital exam was difficult in the office but showed irregularity at the level of sphincter and just above extended as ulceration to anoderm directly overlaying anal sphincters Surgical exam under anesthesia was performed low rectal mass with ulceration extending to anoderm was identified and biopsied Pathological slides were reviewed and showed adenocarcinoma with mucinous features MSI stable. Biopsy from perineal radiation damage field shows radiation changes although early angiosarcoma cannot be excluded CT torso was performed and reviewed and showed no evidence of metastatic disease MRI was reviewed and showed T2 low rectal cancer Initial stage is T2N0M0 - I Multidisciplinary rectal cancer tumor board recommends proceeding with abdominoperineal resection and flap closure of the perineum with referral for possible adjuvant chemotherapy after surgery Past Medical History: vulvar cancer, asthma Family History: non contributory Physical Exam: on discharge; ======================================== Physical exam: Vitals: [MASKED] 0748 Temp: 98.4 PO BP: 136/76 HR: 80 RR: 18 O2 sat: 95% O2 delivery: RA General: AxOx3. Appears well HEENT: Eyes anicteric. PEERLA. EOMI. Mucus membranes appear moist Chest: Symmetric. CTAB. No crackles. No DTP Cards: RRR. Nl S1/S2. No M/R/G. Abdomen: Slightly distended, appropriately tender, no R/G. Incision CDI s/p prevena wound vac(now removed). Abdominal JP, flap JPx2, and vaginal JP with ss output. Neuro: Moving all extremities equally. Sensation grossly intact. [MASKED] strength UE and [MASKED]. Pertinent Results: [MASKED] 05:35AM BLOOD WBC-8.6 RBC-3.48* Hgb-9.5* Hct-29.8* MCV-86 MCH-27.3 MCHC-31.9* RDW-15.1 RDWSD-46.5* Plt [MASKED] [MASKED] 05:35AM BLOOD Plt [MASKED] [MASKED] 05:35AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-140 K-4.0 Cl-107 HCO3-21* AnGap-12 [MASKED] 05:35AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.2 EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: [MASKED] w prior vulvar cancer s/p vulvectomy and chemorad now w Stage I(T2N0M0) rectal ca s/p open APR with colostomy, TAH/BSO and bilateral [MASKED] fasciocutaneous flaps, now with loss of bowel function, n/v, and leukocytosis// Is there an anastomotic leak or an abscess?PO AND IV CONTRAST PLEASE!!!!! TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was administered. IV contrast: 130ml Omnipaque DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 6.1 s, 0.2 cm; CTDIvol = 104.6 mGy (Body) DLP = 20.9 mGy-cm. 3) Spiral Acquisition 7.8 s, 50.4 cm; CTDIvol = 19.9 mGy (Body) DLP = 990.5 mGy-cm. Total DLP (Body) = 1,013 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is minimal dependent atelectasis at the lung bases. ABDOMEN: GENERAL: Trace free fluid is noted in the presacral space. Tiny locules of free air within the left inguinal region (5:70) are likely postsurgical. A percutaneous surgical drain placed from the right anterior abdominal wall terminates in the pelvis. A second drain placed along the left transgluteal approach terminates in the perineum. No drainable fluid collections seen in the abdomen or pelvis. HEPATOBILIARY: The hepatic parenchyma demonstrates homogeneous attenuation with no focal lesions. No intrahepatic biliary ductal dilation. The portal vein and its branches are patent. The gallbladder is surgically absent. PANCREAS: The pancreatic parenchyma enhances homogeneously without main duct dilation. SPLEEN: No splenomegaly or focal splenic lesions. ADRENALS: No adrenal nodules. URINARY: There are likely peripelvic cysts in the left kidney, however given the lack of a delayed exam, presence of underlying hydronephrosis cannot be completely excluded, a dedicated renal ultrasound is recommended. No right-sided hydronephrosis. No solid enhancing renal masses or renal calculi seen. Likely left renal superior pole cysts. GASTROINTESTINAL: Orally ingested contrast is seen opacifying nonobstructed loops of small bowel. There is no extraluminal contrast to suggest presence of a leak. A left lower quadrant colostomy appears intact. LYMPH NODES: There are no enlarged lymph nodes in the abdomen or pelvis.. VASCULAR: There is a moderate amount of calcified atherosclerotic plaque within the abdominal aorta, without aneurysmal dilation. PELVIS: The bladder is decompressed by a Foley catheter. The uterus and adnexae are surgically absent. Trace free fluid in the presacral space is likely postsurgical. No large drainable fluid collection.. Linear hyperdense material in the pelvis (07:30) is compatible with postsurgical material. BONES AND SOFT TISSUES: A fiducial marker is seen in the right perineum. Subacute fractures involving the right inferior and superior pubic rami noted. Degenerative changes of both sacroiliac joints seen. No worrisome osseous lesions identified. Surgical staples project over the midline pelvic wall. Mild stranding of subcutaneous fat within the anterior pelvic wall, is postsurgical. IMPRESSION: 1. There is no leak of orally ingested contrast through the small bowel loops to suggest presence of bowel perforation or leak. No drainable fluid collections identified. A left lower quadrant colostomy without obstruction noted. The colon is not opacified with orally ingested contrast, however is appropriately distended with fluid. No bowel obstruction. 2. Postsurgical changes in the pelvis in the form of trace free pelvic soft tissue stranding and fluid; tiny locules of air in the left inguinal region; surgical drains noted. Brief Hospital Course: Mr/Ms. [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for a APR, post vaginectomy, TAH/BSO, [MASKED] flap. He/She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was controlled with assistance from the [MASKED] service with IV pain medication and an epidural which was transitioned to oral oxycodone and Tylenol once the patient was tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. Had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO after the procedure. She had a post operative ileus and emesis with placement of an NGT for decompression. She began to pass flatus and stool from her ostomy and was started on a bowel regimen. Her NGT was removed and diet was advanced from clear liquids to a regular diet with good tolerability. The patient was tolerating a regular diet at the time of discharge. Patient's intake and output were closely monitored GU: The patient had a Foley catheter that was removed prior to discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient was closely monitored for signs and symptoms of infection and fever. She did have an initial post operative leukocytosis which resolved and remained stable prior to discharge. Heme: The patient had blood levels checked daily during their hospital course to monitor for signs of bleeding. The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay, she was encouraged to get up and ambulate as early as possible. The patient is being discharged on a prophylactic dose of Lovenox for 30 days post operatively. On POD 10, the patient was discharged to Rehab. At discharge, she was tolerating a regular diet, passing gas and stool from her ostomy, voiding, and ambulating with assistance. She will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [x] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [ ] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 2. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr prn Disp #*120 Tablet Refills:*0 2. Enoxaparin Sodium 40 mg SC Q24H RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*23 Syringe Refills:*0 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr prn Disp #*10 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gram by mouth daily Refills:*0 5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 6. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: [MASKED] w prior vulvar cancer s/p vulvectomy and chemorad now w Stage I(T2N0M0) rectal ca s/p open APR with colostomy, TAH/BSO and bilateral [MASKED] fasciocutaneous flaps Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: [MASKED] were admitted to the hospital after an open Ano Peroneal Resection for surgical management of your rectal cancer. [MASKED] also had a TAH/BSO and bilateral fasciocutanous flaps. [MASKED] have recovered from this procedure well and [MASKED] are now ready to return home. Samples of tissue were taken and has been sent to the pathology department. [MASKED] will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact [MASKED] regarding these results they will contact [MASKED] before this time. [MASKED] have a new colostomy. It is important to monitor the output from this stoma. If [MASKED] notice that [MASKED] have not had any stool from your stoma in [MASKED] days, please call the office. Please watch the appearance of the stoma (intestine that protrudes outside of your abdomen), it should be beefy red/pink; if [MASKED] notice that the stoma is turning darker blue or purple please call the office or go to the emergency room. The stoma may ooze small amounts of blood at times when touched but this will improve over time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for any bulging or signs of infection. Please care for the ostomy as [MASKED] have been instructed by the ostomy nurses. [MASKED] will have a visiting nurse at home for the next few weeks to help monitor your ostomy until [MASKED] are comfortable caring for it on your own. If [MASKED] have any of the following symptoms please call the office at [MASKED]: fever greater than 101.5 increasing abdominal distension increasing abdominal pain nausea/vomiting inability to tolerate food or liquids prolonged loose stool extended constipation inability to urinate Incisions: [MASKED] have a long vertical surgical incisions on your abdomen. It is important that [MASKED] monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. [MASKED] may shower; pat the incisions dry with a towel, do not rub. If [MASKED] have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain It is expected that [MASKED] will have pain after surgery, this will gradually improve over the first week or so [MASKED] are home. [MASKED] should continue to take 2 Extra Strength Tylenol ([MASKED]) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. [MASKED] may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days, please take Advil with food. If these medications are not controlling your pain to a point where [MASKED] can ambulate and perform minor tasks, [MASKED] should take a dose of the narcotic pain medication tramadol. Please do not take sedating medications or drink alcohol while taking the narcotic pain medication. Do not drive while taking narcotic medications. [MASKED] will be going home with your JP (surgical) drain, which will be removed at your post-op visit. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently and record output. [MASKED] may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Activity [MASKED] may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear [MASKED] for heavier exercise. In the meantime, [MASKED] may climb stairs, and go outside and walk. Please avoid traveling long distances until [MASKED] speak with your surgical team at your post-op visit. Thank [MASKED] for allowing us to participate in your care, we wish [MASKED] all the best! Followup Instructions: [MASKED]
[]
[ "J45909", "E669" ]
[ "C20: Malignant neoplasm of rectum", "K567: Ileus, unspecified", "J45909: Unspecified asthma, uncomplicated", "N183: Chronic kidney disease, stage 3 (moderate)", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "Z8589: Personal history of malignant neoplasm of other organs and systems" ]
10,067,380
22,274,506
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: codeine / propaxyphene / prednisone / oxybutynin / nitrofurantoin / duloxetine / escitalopram / Darvon / Darvocet-N Attending: ___ ___ Complaint: Left knee osteoarthritis Major Surgical or Invasive Procedure: ___: Left total knee replacement History of Present Illness: Patient is a ___ year old female with history of osteoarthritis who presents with worsening L knee pain over the past year. She was previously booked to have a left knee total knee arthroplasty back in ___ but due to unknown reasons she cancelled. Pt returned to clinic with worsening L>R knee pain and has required a rolling walker for ___ year d/t pain. She received bilateral knee steroid injections in ___, which improved her pain for ___ months. Given these findings and failed non-operative measures, patient has elected to undergo L TKR on ___. Past Medical History: CHF (EF 35%) Dyslipidemia Afib (on xarelto) HTN Ischemic heart disease w/stable angina Gout GERD Recurrent UTI Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:30AM BLOOD WBC-11.7* RBC-2.90* Hgb-9.1* Hct-27.0* MCV-93 MCH-31.4 MCHC-33.7 RDW-15.1 RDWSD-52.5* Plt ___ ___ 06:50AM BLOOD WBC-12.7* RBC-3.74* Hgb-11.6 Hct-34.9 MCV-93 MCH-31.0 MCHC-33.2 RDW-15.0 RDWSD-51.1* Plt ___ ___ 06:40AM BLOOD WBC-12.6* RBC-3.48* Hgb-10.8* Hct-31.9* MCV-92 MCH-31.0 MCHC-33.9 RDW-14.8 RDWSD-49.7* Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:50AM BLOOD K-4.1 ___ 06:40AM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-142 K-4.4 Cl-100 HCO3-25 AnGap-17 ___ 06:50AM BLOOD Mg-1.9 ___ 06:40AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5* Brief Hospital Course: BRIEF HISTORY: 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 had episodes of afib with RVR overnight, which came down with her home Metoprolol. POD#1, she received 5 mg IV Metoprolol for continued afib with RVR. She was given a 500 mL bolus of fluid for a low BP after working with physical therapy. POD#2, Her WBC was 12.7 and she had a tmax of 100.1. She was requiring 1LNC with O2 saturations low to mid 90's. A chest xray was obtained and showed no pneumonia/infectious process. Urine studies were obtained and the urinalysis was negative. The urine culture was pending at time of discharge. The rehab will be contacted if the urine culture comes back positive and needs to be treated. POD#3, the patient was unable to void. A foley was replaced and a voiding trial will be performed on ___ at the rehab. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Xarelto 10 mg daily (half of her home dose) given her high bleeding risk starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to rehab in stable condition. Medications on Admission: 1. Alendronate Sodium 70 mg PO QSUN 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Calcium Carbonate 500 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. cranberry 400 mg oral DAILY 6. Diazepam 10 mg PO Q12H:PRN anxiety 7. Diltiazem Extended-Release 120 mg PO DAILY 8. FoLIC Acid 1 mg PO BID 9. Furosemide 20 mg PO DAILY 10. Acidophilus (Lactobacillus acidophilus) oral DAILY 11. Losartan Potassium 25 mg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID 13. Myrbetriq (mirabegron) 50 mg oral DAILY 14. Nitroglycerin SL 0.4 mg SL PRN chest pain 15. Pantoprazole 40 mg PO Q24H 16. Rivaroxaban 20 mg PO QHS 17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Rivaroxaban 10 mg PO QHS You should remain at 10 mg at bedtime x 4 weeks, then resume 20 mg. 7. Acidophilus (Lactobacillus acidophilus) oral DAILY 8. Alendronate Sodium 70 mg PO QSUN 9. BuPROPion (Sustained Release) 150 mg PO QAM 10. Calcium Carbonate 500 mg PO DAILY 11. cranberry 400 mg oral DAILY 12. Diazepam 10 mg PO Q12H:PRN anxiety 13. Diltiazem Extended-Release 120 mg PO DAILY 14. FoLIC Acid 1 mg PO BID 15. Furosemide 20 mg PO DAILY 16. Losartan Potassium 25 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Myrbetriq (mirabegron) 50 mg oral DAILY 19. Nitroglycerin SL 0.4 mg SL PRN chest pain 20. Pantoprazole 40 mg PO Q24H 21. Vitamin D 1000 UNIT PO DAILY 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 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 xarelto 10 mg daily for four weeks, then resume your home dose of 20 mg daily to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 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: KNEES: WBAT affected extremity 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: ___
[ "M1712", "I5032", "I110", "E785", "I4891", "E669", "Z6835", "Z87891", "Z7902" ]
Allergies: codeine / propaxyphene / prednisone / oxybutynin / nitrofurantoin / duloxetine / escitalopram / Darvon / Darvocet-N [MASKED] Complaint: Left knee osteoarthritis Major Surgical or Invasive Procedure: [MASKED]: Left total knee replacement History of Present Illness: Patient is a [MASKED] year old female with history of osteoarthritis who presents with worsening L knee pain over the past year. She was previously booked to have a left knee total knee arthroplasty back in [MASKED] but due to unknown reasons she cancelled. Pt returned to clinic with worsening L>R knee pain and has required a rolling walker for [MASKED] year d/t pain. She received bilateral knee steroid injections in [MASKED], which improved her pain for [MASKED] months. Given these findings and failed non-operative measures, patient has elected to undergo L TKR on [MASKED]. Past Medical History: CHF (EF 35%) Dyslipidemia Afib (on xarelto) HTN Ischemic heart disease w/stable angina Gout GERD Recurrent UTI Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:30AM BLOOD WBC-11.7* RBC-2.90* Hgb-9.1* Hct-27.0* MCV-93 MCH-31.4 MCHC-33.7 RDW-15.1 RDWSD-52.5* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-12.7* RBC-3.74* Hgb-11.6 Hct-34.9 MCV-93 MCH-31.0 MCHC-33.2 RDW-15.0 RDWSD-51.1* Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-12.6* RBC-3.48* Hgb-10.8* Hct-31.9* MCV-92 MCH-31.0 MCHC-33.9 RDW-14.8 RDWSD-49.7* Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 06:50AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:50AM BLOOD K-4.1 [MASKED] 06:40AM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-142 K-4.4 Cl-100 HCO3-25 AnGap-17 [MASKED] 06:50AM BLOOD Mg-1.9 [MASKED] 06:40AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5* Brief Hospital Course: BRIEF HISTORY: 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 had episodes of afib with RVR overnight, which came down with her home Metoprolol. POD#1, she received 5 mg IV Metoprolol for continued afib with RVR. She was given a 500 mL bolus of fluid for a low BP after working with physical therapy. POD#2, Her WBC was 12.7 and she had a tmax of 100.1. She was requiring 1LNC with O2 saturations low to mid 90's. A chest xray was obtained and showed no pneumonia/infectious process. Urine studies were obtained and the urinalysis was negative. The urine culture was pending at time of discharge. The rehab will be contacted if the urine culture comes back positive and needs to be treated. POD#3, the patient was unable to void. A foley was replaced and a voiding trial will be performed on [MASKED] at the rehab. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Xarelto 10 mg daily (half of her home dose) given her high bleeding risk starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [MASKED] is discharged to rehab in stable condition. Medications on Admission: 1. Alendronate Sodium 70 mg PO QSUN 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Calcium Carbonate 500 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. cranberry 400 mg oral DAILY 6. Diazepam 10 mg PO Q12H:PRN anxiety 7. Diltiazem Extended-Release 120 mg PO DAILY 8. FoLIC Acid 1 mg PO BID 9. Furosemide 20 mg PO DAILY 10. Acidophilus (Lactobacillus acidophilus) oral DAILY 11. Losartan Potassium 25 mg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID 13. Myrbetriq (mirabegron) 50 mg oral DAILY 14. Nitroglycerin SL 0.4 mg SL PRN chest pain 15. Pantoprazole 40 mg PO Q24H 16. Rivaroxaban 20 mg PO QHS 17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Rivaroxaban 10 mg PO QHS You should remain at 10 mg at bedtime x 4 weeks, then resume 20 mg. 7. Acidophilus (Lactobacillus acidophilus) oral DAILY 8. Alendronate Sodium 70 mg PO QSUN 9. BuPROPion (Sustained Release) 150 mg PO QAM 10. Calcium Carbonate 500 mg PO DAILY 11. cranberry 400 mg oral DAILY 12. Diazepam 10 mg PO Q12H:PRN anxiety 13. Diltiazem Extended-Release 120 mg PO DAILY 14. FoLIC Acid 1 mg PO BID 15. Furosemide 20 mg PO DAILY 16. Losartan Potassium 25 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Myrbetriq (mirabegron) 50 mg oral DAILY 19. Nitroglycerin SL 0.4 mg SL PRN chest pain 20. Pantoprazole 40 mg PO Q24H 21. Vitamin D 1000 UNIT PO DAILY 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 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 xarelto 10 mg daily for four weeks, then resume your home dose of 20 mg daily to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 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: KNEES: WBAT affected extremity 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]
[]
[ "I5032", "I110", "E785", "I4891", "E669", "Z87891", "Z7902" ]
[ "M1712: Unilateral primary osteoarthritis, left knee", "I5032: Chronic diastolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "E785: Hyperlipidemia, unspecified", "I4891: Unspecified atrial fibrillation", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,067,389
23,577,021
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: endotracheal intubation - ___ ___ placement - ___ LUE midline placement - ___ History of Present Illness: Mr ___ is a ___ h/o HTN, HLD, T2DM, HFpEF, symptomatic bradycardia s/p PPM placement ___ ___ Azure XT dual chamber MRI), CKD recently briefly on HD for ATN now off who presented in transfer from ___ with PEA arrest. Per son, patient was his usual self in the preceding hours, and the son had just left him after dinner. Around 7:30 pm the son received a phone call that his father was found in his room unresponsive with evidence of emesis. Downtime was unclear but likely less than 15 minutes. He was found to be in PEA arrest. He received 3 rounds of epi and was intubated in the field. He was taken to the ___ with active CPR in progress. On arrival to ___ he was noted to have evidence of possible aspiration and emesis. He was treated empirically for possible hyperkalemia with calcium, bicarb, epi, IV fluids. ROSC was achieved. ECG showed afib with LVH, STD V3-V6. He was started on levophed for downtrending BPs and transferred to ___. In total, patient received 3 rounds of epi and CPR w/ ROSC. Of note, patient has had several admissions recently to ___ and ___ with different complications. He was first admitted to ___ with symptomatic bradycardia for which he received PPM placement c/b developed hypoxemic respiratory failure requiring intubation likely iso volume overload and pneumosepsis, c/b AMS, worsening kidney function requiring HD. He was finally discharged to ___ but represented 1 day later with an episode of unresponsiveness while sitting in his chair, in which he had garbled speech and slumped to the sit. This was found to be in the setting of another infection, and patient has had multiple ___ visits since with UTIs and other infections with MDR patters (see ___ records). In the ___, patient was noted to be hypotensive and hypothermic. Initial Vitals: HR60, BP146/86, RR32 Exam: GCS 3 not on sedation, fixed dilated pupils, vomitus at mouth. no lower leg edema, Cardiac/pulm/abd exam wnl, no rashes. Cold and clammy. Labs: WBC:7.4 Hgb:6.3 Plt:122 148|122| 58 AGap=15 (HEMOLYZED SAMPLE) -------------<65 6.3| 10|3.2 Ca: 8.2 Mg: 1.9 P: 7.7 ALT: Pnd AP: Pnd Tbili: Pnd Alb: Pnd AST: Pnd LDH: Dbili: TProt: ___: Lip: Pnd ___: 19.6 PTT: 36.1 INR: 1.8 Trop 0.20 VBG 21:46: 7.19/20/HCO3 16. Whole blood Na 146, K 5.1, Cl 119, Glu 226, Lactate 6.0, Hgb 6.7 Cr 3.5. O2Sat: 89 VBG 21:%5 ___ O2 sat 56 Imaging: CT Chest W/O Contrast [0] -- Study Ordered CT Abd & Pelvis W/O Contrast [0] -- Study Ordered CT Head W/O Contrast [0] -- Study Ordered ___ 21:24 CXR: Enteric tube courses below the diaphragm, out of the field of view; gastric bubble appears distended. Endotracheal tube terminates 6 cm above the carina. Left base opacity likely represents combination of pleural effusion and atelectasis, underlying consolidation not excluded. Consults: Post- arrest team who recommended cooling to 34-36 deg w/ ___ ___ Cardiology who did not think there was acute coronary pathology and recommended admission to MICU. Interventions: ___ 21:22 IV DRIP NORepinephrine Started 0.1 mcg/kg/min ___ 21:29 IV DRIP NORepinephrine Rate Changed to 0.3 mcg/kg/min ___ 21:32 IV DRIP EPINEPHrine Started 0.05 mcg/kg/min ___ 22:08 IV DRIP NORepinephrine Rate Changed to 0.2 mcg/kg/min ___ 22:29 IV DRIP NORepinephrine Rate Changed to 0.15 mcg/kg/min ___ 22:42 IV Fentanyl Citrate 100 mcg ___ 22:44 IV DRIP NORepinephrine Rate Changed to 0.1 mcg/kg/min ___ 23:15 IV CefePIME (2 g ordered) ___ 23:15 IVF LR ( 1000 mL ordered) ___ 23:16 IV DRIP EPINEPHrine ___ 23:17 IV DRIP NORepinephrine Patient had another episode of PEA arrest for which he received CPR with ROSC. a-line was placed in ___ 3 attempts R Radial VS Prior to Transfer: T90.0, HR60, BP153/80, RR20, 100% Intubation Past Medical History: Congestive heart failure Chronic kidney disease (CKD) Benign prostatic hyperplasia Hypertensive disorder Gastroesophageal reflux disease Diabetes mellitus Bradycardia Pacemaker Hemodialysis patient Social History: ___ Family History: Not relevant to current presentation. Physical Exam: ADMISSION EXAM ============== VS: T 88.5, HR 60, BP 143/100, RR 20, 100% GEN: intubated, sedated, unresponsive to touch, voice or pain HEENT: pupils fixed and dilated, ETT in place NECK: supple, no LAD CV: rrr no m/g/r RESP: ctab, transmitted breath sounds from vent GI: soft, NT, ND, normal bowel sounds MSK: wwp, 3+ pitting edema to knee SKIN: no wounds appreciated NEURO: +corneal reflex, +gag, could not elicit purposeful responses PSYCH: unable to assess DISCHARGE EXAM ============== VS: Reviewed in MetaVision GENERAL: intubated, sedated, unresponsive to touch, voice or pain HEENT: pupils dilated at 4mm, sluggishly responsive NECK: supple, no LAD CV: RRR, S1+S2 normal, no M/R/G RESP: CTAB, transmitted breath sounds, no wheezes or crackles ___: soft, non-tender, no distention, normal bowel sounds EXTREMITIES: warm, well perfused, 3+ pitting edema to knees SKIN: no wounds appreciated NEURO: -corneal reflex, -gag, could not elicit purposeful responses PSYCH: unable to assess Pertinent Results: =============== ADMISSION LABS: =============== ___ 09:40PM WBC-7.4 RBC-2.14* HGB-6.3* HCT-22.1* MCV-103* MCH-29.4 MCHC-28.5* RDW-16.6* RDWSD-62.4* ___ 09:40PM NEUTS-33* LYMPHS-66* MONOS-1* EOS-0* BASOS-0 AbsNeut-2.44 AbsLymp-4.88* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* ___ 09:40PM ANISOCYT-1+* MACROCYT-1+* SPHEROCYT-1+* RBCM-SLIDE REVI ___ 09:40PM PLT SMR-NORMAL PLT COUNT-122* ___ 09:40PM ___ PTT-36.1 ___ ___ 09:40PM GLUCOSE-65* UREA N-58* CREAT-3.2* SODIUM-148* POTASSIUM-6.3* CHLORIDE-122* TOTAL CO2-10* ANION GAP-15 ___ 09:40PM CALCIUM-8.2* PHOSPHATE-7.7* MAGNESIUM-1.9 ___ 09:40PM cTropnT-0.20* ___ 09:46PM ___ PO2-91 PCO2-40 PH-7.19* TOTAL CO2-16* BASE XS--12 COMMENTS-GREEN TOP ___ 09:46PM GLUCOSE-226* LACTATE-6.0* CREAT-3.5* NA+-146 K+-5.1 CL--119* ===================== PERTINENT LABS/MICRO: ===================== ___ URINE CULTURE - Yeast >100,000 CFU/ml ___ SPUTUM CULTURE - commensal respiratory flora ___ BLOOD CULTURE x3 - no growth ___ URINE CULTURE - ENTEROCOCCUS >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R ================ IMAGING/STUDIES: ================ ___ CXR Enteric tube courses below the diaphragm, out of the field of view; gastric bubble appears distended. Endotracheal tube terminates 6 cm above the carina. Left base opacity likely represents combination of pleural effusion and atelectasis, underlying consolidation not excluded. ___ CT HEAD WITHOUT CONTRAST 3.1 cm area of subcortical hypodensity in the left occipital lobe extending to the posterior horn of the left lateral ventricle which could represent evolving subacute infarct, but age-indeterminate. There is also subtle blurring of gray-white differentiation along the left frontal parietal vertex, which may represent an early developing infarct. Recommend further evaluation with MRI, if not contraindicated, for more definitive evaluation and to exclude underlying lesion. ___ CT TORSO WITHOUT CONTRAST Moderate volume ascites, bilateral moderate pleural effusions in body wall edema also likely reflect third spacing. Poor definition of the gallbladder, which may warrant focused ultrasound if there is concern for acute gallbladder process. Oblique, non displaced fracture of the upper sternum, likely the sequelae of CPR. Mildly displaced fracture of the anterolateral left seventh rib. Multiple fluid-filled loops of small bowel suggestive of ileus. Pars defects with moderate-severe anterolisthesis of L4 over L5 with moderate-severe spinal canal narrowing. Compressive atelectasis of the left lower lobe. Subtle ___ micronodular opacity in the right lower lobe may reflect sequelae of trace aspiration. Small pericardial effusion. Severe diffuse atherosclerotic arterial calcification. ___ LIVER/GALLBLADDER US Multiple stones and sludge seen within a nondistended gallbladder. The gallbladder wall is thickened however there is no hyperemia or pericholecystic fluid, which is likely sequela from right heart dysfunction or fluid status. No evidence of gallbladder perforation. Normal appearing liver. Patent portal vein. Moderate right upper quadrant ascites. ___ LOWER EXTREMITY DOPPLER US No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ CXR Interval placement of a right PICC with tip projecting over the right atrium. Retraction of the catheter by approximately 4 cm is recommended for optimal positioning. Otherwise, no significant change in lung and heart findings compared to the prior study. ___ TTE The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is SEVERE symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50-55%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No valvular systolic anterior motion (___) is present. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is high normal. There is a very small circumferential pericardial effusion. A left pleural effusion is present. ___ MRI/MRA Brain Global anoxic brain injury. Subacute infarctions in the left occipital lobe and bilateral medial temporal lobes. ___ EEG Periods lasting up to 30 minutes with diffuse rhythmic myogenic artifact at ___ Hz, sometimes with a left sided preponderance, and often associated with rhythmic face or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Periods of prolonged diffuse suppression, lack of reactivity, and diffuse slowing in the background. This indicates severe diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include diffuse hypoxic ischemic injury, medications/sedation, and severe toxic metabolic disturbances and infections. ___ EEG Infrequent events lasting up to 10 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Persistent diffuse suppression, lack of reactivity, and diffuse slowing in the background. This indicates severe diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include diffuse hypoxic ischemic injury, medications/sedation, and severe toxic metabolic disturbances and infections. This pattern at greater than 72 hours post cardiac arrest is associated with poor neurological outcome. ___ EEG One event lasting up to 20 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. ___ KUB Enteric tube terminates in the distal stomach. There is an overall paucity of bowel gas. There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications. A cardiac pacer lead is partially visualized. A rectal probe is seen projecting over the midline pelvis. ___ EEG Frequent events between 07:00 and 09:00, lasting up to 25 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or shoulder movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. ___ EEG Frequent isolated diffuse myogenic artifact associated with rhythmic head or face movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. ___ EEG Frequent epochs of diffuse rhythmic myogenic artifact associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression with lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 2 pushbutton activations as described above. Compared to the prior day's study, there is no significant change. ___ EEG Frequent periods of diffuse myogenic artifacts associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 2 pushbutton activations as described above. There are no electrographic seizures. Compared to the prior day's study, there is no significant change. ___ EEG Intermittent periods of diffuse myogenic artifacts associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 3 pushbutton activations as described above. There are no electrographic seizures. Compared to the prior day's study, there is no significant change. =============== DISCHARGE LABS: =============== ___ 03:01AM BLOOD WBC-9.5 RBC-2.39* Hgb-7.0* Hct-21.8* MCV-91 MCH-29.3 MCHC-32.1 RDW-15.7* RDWSD-52.0* Plt ___ ___ 03:01AM BLOOD ___ PTT-30.6 ___ ___ 03:01AM BLOOD Glucose-118* UreaN-102* Creat-9.5* Na-134* K-6.2* Cl-103 HCO3-11* AnGap-20* ___ 03:01AM BLOOD Calcium-6.9* Phos-10.7* Mg-2.___ with a history of HTN, HLD, T2DM, HFpEF, symptomatic bradycardia s/p PPM placement ___, CKD secondary to ATN (recently briefly on HD), who presented in transfer from ___ ___ following PEA arrest. ============= ACUTE ISSUES: ============= # Status post PEA arrest Found down with vomitus around him after an unknown amount of time on ___. ROSC obtained after 3 rounds of epinephrine, though patient lost pulse again briefly at ___ ___. Most likely etiology was stroke leading to aspiration and PEA arrest, based on MRI/MRA brain findings on ___. Started on Keppra for prophylaxis. EEG initially with burst suppression activity, subsequently became more flat, and MRI demonstrated global anoxic injury, consistent with poor neurological prognosis. Patient was assessed by two different neurologists to provide two opinions; examination did demonstrate brainstem reflexes, however based on other findings, inclusive of lack of spontaneous movement off sedation (only having myoclonic jerking), the odds of meaningful neurological recovery were felt to be poor. Extensive family discussion regarding same; eventually decision was made to terminally extubate given poor neurological and renal prognosis. Pt died shortly thereafter. # Acute renal failure # Hyperkalemia # Hyperphosphatemia Recent baseline creatinine ~3.0 since coming off HD. Creatinine 3.2 on admission. No improvement with volume resuscitation. Was felt to likely be ATN in the setting of cardiac arrest. Creatinine continued to uptrend, and did not reach a peak. Patient was anuric with rising potassium/phosphate and worsening acidosis over the course of admission, requiring intermittent temporization. It was felt patient would not be a candidate for HD given poor neurological prognosis, as such this was not offered to the family. Ultimately became hyperkalemic with subsequent arrhythmias. # Hypoglycemia Recurrent hypoglycemia during admission, requiring multiple rounds of D50 over the course of admission. Eventually was started on D10W infusion to maintain euglycemia. # Aspiration pneumonia vs. pneumonitis # Acute hypoxic respiratory failure Noted on initial CT, mostly left-sided. Given MDR resistance pattern in prior ___ urine cultures, initially was started on vancomycin/meropenem to allow for broad coverage - deescalated to vancomycin/Zosyn per antibiotic stewardship team on ___. Given negative culture data, absence of fevers and normal WBC, it was felt this likely represented aspiration pneumonitis rather than pneumonia. Antibiotics were discontinued on ___ without evidence of ongoing or recurrent infection over the course of the admission. # VRE bacteruria Growing VRE in urine, without pyuria on urinalysis. Was on ertapenem at facility prior to admission (D1 = ___. Sample was drawn from Foley, so unclear significance of same. Repeat urine culture grew yeast only, in setting of Foley use. No antibiotic therapy was started. # Acute on chronic anemia Hgb in 8s on previous checks in the last month prior to admission, had acute drop to 6.8 on admission, however with appropriate response to transfusion. Likely reflected combination of bone marrow suppression and anemia of chronic disease in setting of CKD. # Transaminitis Likely shock liver in setting of PEA arrest. RUQUS without any acute pathology on admission. Improved over course of admission given no further ischemic insults. Aorvastatin was held. # Hypertension Was an ongoing issue since admission and discontinuation of sedation. Required nitroglycerin drip to optimize blood pressure control initially, but restarted home anti-hypertensive medications on ___, with subsequent weaning off nitroglycerin drip and resolution of hypertension. Continued carvedilol 25mg BID and amlodipine 5mg daily thereafter. =============== CHRONIC ISSUES: =============== # BPH Continued finasteride 5mg daily and held tamsulosin initially. Discontinued finasteride in setting of Foley use. # GERD IV famotidine in place of home omeprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Ascorbic Acid ___ mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 6. CARVedilol 25 mg PO BID 7. Vitamin D ___ UNIT PO 1X/WEEK (WE) 8. Finasteride 5 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Fleet Enema (Saline) ___AILY:PRN constipation 12. Tamsulosin 0.8 mg PO QHS 13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Calcitriol 0.25 mcg PO DAILY 16. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 17. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line Discharge Medications: pt deceased Discharge Disposition: Expired Discharge Diagnosis: pt deceased Discharge Condition: pt deceased Discharge Instructions: pt deceased Followup Instructions: ___
[ "J690", "L89153", "I639", "N170", "J9601", "K7201", "E872", "I130", "I5032", "G931", "I468", "Z66", "Z515", "Z45018", "R402433", "Z87891", "E875", "E8339", "R8271", "B952", "D631", "Z006", "N400", "K219", "Z794", "E785", "E1122", "N189", "I495", "R680", "R569", "E11649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: endotracheal intubation - [MASKED] [MASKED] placement - [MASKED] LUE midline placement - [MASKED] History of Present Illness: Mr [MASKED] is a [MASKED] h/o HTN, HLD, T2DM, HFpEF, symptomatic bradycardia s/p PPM placement [MASKED] [MASKED] Azure XT dual chamber MRI), CKD recently briefly on HD for ATN now off who presented in transfer from [MASKED] with PEA arrest. Per son, patient was his usual self in the preceding hours, and the son had just left him after dinner. Around 7:30 pm the son received a phone call that his father was found in his room unresponsive with evidence of emesis. Downtime was unclear but likely less than 15 minutes. He was found to be in PEA arrest. He received 3 rounds of epi and was intubated in the field. He was taken to the [MASKED] with active CPR in progress. On arrival to [MASKED] he was noted to have evidence of possible aspiration and emesis. He was treated empirically for possible hyperkalemia with calcium, bicarb, epi, IV fluids. ROSC was achieved. ECG showed afib with LVH, STD V3-V6. He was started on levophed for downtrending BPs and transferred to [MASKED]. In total, patient received 3 rounds of epi and CPR w/ ROSC. Of note, patient has had several admissions recently to [MASKED] and [MASKED] with different complications. He was first admitted to [MASKED] with symptomatic bradycardia for which he received PPM placement c/b developed hypoxemic respiratory failure requiring intubation likely iso volume overload and pneumosepsis, c/b AMS, worsening kidney function requiring HD. He was finally discharged to [MASKED] but represented 1 day later with an episode of unresponsiveness while sitting in his chair, in which he had garbled speech and slumped to the sit. This was found to be in the setting of another infection, and patient has had multiple [MASKED] visits since with UTIs and other infections with MDR patters (see [MASKED] records). In the [MASKED], patient was noted to be hypotensive and hypothermic. Initial Vitals: HR60, BP146/86, RR32 Exam: GCS 3 not on sedation, fixed dilated pupils, vomitus at mouth. no lower leg edema, Cardiac/pulm/abd exam wnl, no rashes. Cold and clammy. Labs: WBC:7.4 Hgb:6.3 Plt:122 148|122| 58 AGap=15 (HEMOLYZED SAMPLE) -------------<65 6.3| 10|3.2 Ca: 8.2 Mg: 1.9 P: 7.7 ALT: Pnd AP: Pnd Tbili: Pnd Alb: Pnd AST: Pnd LDH: Dbili: TProt: [MASKED]: Lip: Pnd [MASKED]: 19.6 PTT: 36.1 INR: 1.8 Trop 0.20 VBG 21:46: 7.19/20/HCO3 16. Whole blood Na 146, K 5.1, Cl 119, Glu 226, Lactate 6.0, Hgb 6.7 Cr 3.5. O2Sat: 89 VBG 21:%5 [MASKED] O2 sat 56 Imaging: CT Chest W/O Contrast [0] -- Study Ordered CT Abd & Pelvis W/O Contrast [0] -- Study Ordered CT Head W/O Contrast [0] -- Study Ordered [MASKED] 21:24 CXR: Enteric tube courses below the diaphragm, out of the field of view; gastric bubble appears distended. Endotracheal tube terminates 6 cm above the carina. Left base opacity likely represents combination of pleural effusion and atelectasis, underlying consolidation not excluded. Consults: Post- arrest team who recommended cooling to 34-36 deg w/ [MASKED] [MASKED] Cardiology who did not think there was acute coronary pathology and recommended admission to MICU. Interventions: [MASKED] 21:22 IV DRIP NORepinephrine Started 0.1 mcg/kg/min [MASKED] 21:29 IV DRIP NORepinephrine Rate Changed to 0.3 mcg/kg/min [MASKED] 21:32 IV DRIP EPINEPHrine Started 0.05 mcg/kg/min [MASKED] 22:08 IV DRIP NORepinephrine Rate Changed to 0.2 mcg/kg/min [MASKED] 22:29 IV DRIP NORepinephrine Rate Changed to 0.15 mcg/kg/min [MASKED] 22:42 IV Fentanyl Citrate 100 mcg [MASKED] 22:44 IV DRIP NORepinephrine Rate Changed to 0.1 mcg/kg/min [MASKED] 23:15 IV CefePIME (2 g ordered) [MASKED] 23:15 IVF LR ( 1000 mL ordered) [MASKED] 23:16 IV DRIP EPINEPHrine [MASKED] 23:17 IV DRIP NORepinephrine Patient had another episode of PEA arrest for which he received CPR with ROSC. a-line was placed in [MASKED] 3 attempts R Radial VS Prior to Transfer: T90.0, HR60, BP153/80, RR20, 100% Intubation Past Medical History: Congestive heart failure Chronic kidney disease (CKD) Benign prostatic hyperplasia Hypertensive disorder Gastroesophageal reflux disease Diabetes mellitus Bradycardia Pacemaker Hemodialysis patient Social History: [MASKED] Family History: Not relevant to current presentation. Physical Exam: ADMISSION EXAM ============== VS: T 88.5, HR 60, BP 143/100, RR 20, 100% GEN: intubated, sedated, unresponsive to touch, voice or pain HEENT: pupils fixed and dilated, ETT in place NECK: supple, no LAD CV: rrr no m/g/r RESP: ctab, transmitted breath sounds from vent GI: soft, NT, ND, normal bowel sounds MSK: wwp, 3+ pitting edema to knee SKIN: no wounds appreciated NEURO: +corneal reflex, +gag, could not elicit purposeful responses PSYCH: unable to assess DISCHARGE EXAM ============== VS: Reviewed in MetaVision GENERAL: intubated, sedated, unresponsive to touch, voice or pain HEENT: pupils dilated at 4mm, sluggishly responsive NECK: supple, no LAD CV: RRR, S1+S2 normal, no M/R/G RESP: CTAB, transmitted breath sounds, no wheezes or crackles [MASKED]: soft, non-tender, no distention, normal bowel sounds EXTREMITIES: warm, well perfused, 3+ pitting edema to knees SKIN: no wounds appreciated NEURO: -corneal reflex, -gag, could not elicit purposeful responses PSYCH: unable to assess Pertinent Results: =============== ADMISSION LABS: =============== [MASKED] 09:40PM WBC-7.4 RBC-2.14* HGB-6.3* HCT-22.1* MCV-103* MCH-29.4 MCHC-28.5* RDW-16.6* RDWSD-62.4* [MASKED] 09:40PM NEUTS-33* LYMPHS-66* MONOS-1* EOS-0* BASOS-0 AbsNeut-2.44 AbsLymp-4.88* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* [MASKED] 09:40PM ANISOCYT-1+* MACROCYT-1+* SPHEROCYT-1+* RBCM-SLIDE REVI [MASKED] 09:40PM PLT SMR-NORMAL PLT COUNT-122* [MASKED] 09:40PM [MASKED] PTT-36.1 [MASKED] [MASKED] 09:40PM GLUCOSE-65* UREA N-58* CREAT-3.2* SODIUM-148* POTASSIUM-6.3* CHLORIDE-122* TOTAL CO2-10* ANION GAP-15 [MASKED] 09:40PM CALCIUM-8.2* PHOSPHATE-7.7* MAGNESIUM-1.9 [MASKED] 09:40PM cTropnT-0.20* [MASKED] 09:46PM [MASKED] PO2-91 PCO2-40 PH-7.19* TOTAL CO2-16* BASE XS--12 COMMENTS-GREEN TOP [MASKED] 09:46PM GLUCOSE-226* LACTATE-6.0* CREAT-3.5* NA+-146 K+-5.1 CL--119* ===================== PERTINENT LABS/MICRO: ===================== [MASKED] URINE CULTURE - Yeast >100,000 CFU/ml [MASKED] SPUTUM CULTURE - commensal respiratory flora [MASKED] BLOOD CULTURE x3 - no growth [MASKED] URINE CULTURE - ENTEROCOCCUS >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R ================ IMAGING/STUDIES: ================ [MASKED] CXR Enteric tube courses below the diaphragm, out of the field of view; gastric bubble appears distended. Endotracheal tube terminates 6 cm above the carina. Left base opacity likely represents combination of pleural effusion and atelectasis, underlying consolidation not excluded. [MASKED] CT HEAD WITHOUT CONTRAST 3.1 cm area of subcortical hypodensity in the left occipital lobe extending to the posterior horn of the left lateral ventricle which could represent evolving subacute infarct, but age-indeterminate. There is also subtle blurring of gray-white differentiation along the left frontal parietal vertex, which may represent an early developing infarct. Recommend further evaluation with MRI, if not contraindicated, for more definitive evaluation and to exclude underlying lesion. [MASKED] CT TORSO WITHOUT CONTRAST Moderate volume ascites, bilateral moderate pleural effusions in body wall edema also likely reflect third spacing. Poor definition of the gallbladder, which may warrant focused ultrasound if there is concern for acute gallbladder process. Oblique, non displaced fracture of the upper sternum, likely the sequelae of CPR. Mildly displaced fracture of the anterolateral left seventh rib. Multiple fluid-filled loops of small bowel suggestive of ileus. Pars defects with moderate-severe anterolisthesis of L4 over L5 with moderate-severe spinal canal narrowing. Compressive atelectasis of the left lower lobe. Subtle [MASKED] micronodular opacity in the right lower lobe may reflect sequelae of trace aspiration. Small pericardial effusion. Severe diffuse atherosclerotic arterial calcification. [MASKED] LIVER/GALLBLADDER US Multiple stones and sludge seen within a nondistended gallbladder. The gallbladder wall is thickened however there is no hyperemia or pericholecystic fluid, which is likely sequela from right heart dysfunction or fluid status. No evidence of gallbladder perforation. Normal appearing liver. Patent portal vein. Moderate right upper quadrant ascites. [MASKED] LOWER EXTREMITY DOPPLER US No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED] CXR Interval placement of a right PICC with tip projecting over the right atrium. Retraction of the catheter by approximately 4 cm is recommended for optimal positioning. Otherwise, no significant change in lung and heart findings compared to the prior study. [MASKED] TTE The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is SEVERE symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50-55%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No valvular systolic anterior motion ([MASKED]) is present. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is high normal. There is a very small circumferential pericardial effusion. A left pleural effusion is present. [MASKED] MRI/MRA Brain Global anoxic brain injury. Subacute infarctions in the left occipital lobe and bilateral medial temporal lobes. [MASKED] EEG Periods lasting up to 30 minutes with diffuse rhythmic myogenic artifact at [MASKED] Hz, sometimes with a left sided preponderance, and often associated with rhythmic face or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Periods of prolonged diffuse suppression, lack of reactivity, and diffuse slowing in the background. This indicates severe diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include diffuse hypoxic ischemic injury, medications/sedation, and severe toxic metabolic disturbances and infections. [MASKED] EEG Infrequent events lasting up to 10 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Persistent diffuse suppression, lack of reactivity, and diffuse slowing in the background. This indicates severe diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include diffuse hypoxic ischemic injury, medications/sedation, and severe toxic metabolic disturbances and infections. This pattern at greater than 72 hours post cardiac arrest is associated with poor neurological outcome. [MASKED] EEG One event lasting up to 20 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or jaw movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. [MASKED] KUB Enteric tube terminates in the distal stomach. There is an overall paucity of bowel gas. There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications. A cardiac pacer lead is partially visualized. A rectal probe is seen projecting over the midline pelvis. [MASKED] EEG Frequent events between 07:00 and 09:00, lasting up to 25 minutes with diffuse rhythmic myogenic artifact at 2.5-3.5 Hz associated with rhythmic head, face, or shoulder movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. [MASKED] EEG Frequent isolated diffuse myogenic artifact associated with rhythmic head or face movements. This finding could indicate either cortically or subcortically generated myoclonus, and is highly characteristic of diffuse hypoxic ischemic injury. Diffuse back suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. [MASKED] EEG Frequent epochs of diffuse rhythmic myogenic artifact associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression with lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 2 pushbutton activations as described above. Compared to the prior day's study, there is no significant change. [MASKED] EEG Frequent periods of diffuse myogenic artifacts associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 2 pushbutton activations as described above. There are no electrographic seizures. Compared to the prior day's study, there is no significant change. [MASKED] EEG Intermittent periods of diffuse myogenic artifacts associated with rhythmic head or face movements. This finding could indicate myoclonus of either cortical or subcortical origin, and is often seen with diffuse hypoxic ischemic injury. Diffuse background suppression and lack of reactivity, indicative of severe diffuse cerebral dysfunction that is nonspecific in etiology. There are 3 pushbutton activations as described above. There are no electrographic seizures. Compared to the prior day's study, there is no significant change. =============== DISCHARGE LABS: =============== [MASKED] 03:01AM BLOOD WBC-9.5 RBC-2.39* Hgb-7.0* Hct-21.8* MCV-91 MCH-29.3 MCHC-32.1 RDW-15.7* RDWSD-52.0* Plt [MASKED] [MASKED] 03:01AM BLOOD [MASKED] PTT-30.6 [MASKED] [MASKED] 03:01AM BLOOD Glucose-118* UreaN-102* Creat-9.5* Na-134* K-6.2* Cl-103 HCO3-11* AnGap-20* [MASKED] 03:01AM BLOOD Calcium-6.9* Phos-10.7* Mg-2.[MASKED] with a history of HTN, HLD, T2DM, HFpEF, symptomatic bradycardia s/p PPM placement [MASKED], CKD secondary to ATN (recently briefly on HD), who presented in transfer from [MASKED] [MASKED] following PEA arrest. ============= ACUTE ISSUES: ============= # Status post PEA arrest Found down with vomitus around him after an unknown amount of time on [MASKED]. ROSC obtained after 3 rounds of epinephrine, though patient lost pulse again briefly at [MASKED] [MASKED]. Most likely etiology was stroke leading to aspiration and PEA arrest, based on MRI/MRA brain findings on [MASKED]. Started on Keppra for prophylaxis. EEG initially with burst suppression activity, subsequently became more flat, and MRI demonstrated global anoxic injury, consistent with poor neurological prognosis. Patient was assessed by two different neurologists to provide two opinions; examination did demonstrate brainstem reflexes, however based on other findings, inclusive of lack of spontaneous movement off sedation (only having myoclonic jerking), the odds of meaningful neurological recovery were felt to be poor. Extensive family discussion regarding same; eventually decision was made to terminally extubate given poor neurological and renal prognosis. Pt died shortly thereafter. # Acute renal failure # Hyperkalemia # Hyperphosphatemia Recent baseline creatinine ~3.0 since coming off HD. Creatinine 3.2 on admission. No improvement with volume resuscitation. Was felt to likely be ATN in the setting of cardiac arrest. Creatinine continued to uptrend, and did not reach a peak. Patient was anuric with rising potassium/phosphate and worsening acidosis over the course of admission, requiring intermittent temporization. It was felt patient would not be a candidate for HD given poor neurological prognosis, as such this was not offered to the family. Ultimately became hyperkalemic with subsequent arrhythmias. # Hypoglycemia Recurrent hypoglycemia during admission, requiring multiple rounds of D50 over the course of admission. Eventually was started on D10W infusion to maintain euglycemia. # Aspiration pneumonia vs. pneumonitis # Acute hypoxic respiratory failure Noted on initial CT, mostly left-sided. Given MDR resistance pattern in prior [MASKED] urine cultures, initially was started on vancomycin/meropenem to allow for broad coverage - deescalated to vancomycin/Zosyn per antibiotic stewardship team on [MASKED]. Given negative culture data, absence of fevers and normal WBC, it was felt this likely represented aspiration pneumonitis rather than pneumonia. Antibiotics were discontinued on [MASKED] without evidence of ongoing or recurrent infection over the course of the admission. # VRE bacteruria Growing VRE in urine, without pyuria on urinalysis. Was on ertapenem at facility prior to admission (D1 = [MASKED]. Sample was drawn from Foley, so unclear significance of same. Repeat urine culture grew yeast only, in setting of Foley use. No antibiotic therapy was started. # Acute on chronic anemia Hgb in 8s on previous checks in the last month prior to admission, had acute drop to 6.8 on admission, however with appropriate response to transfusion. Likely reflected combination of bone marrow suppression and anemia of chronic disease in setting of CKD. # Transaminitis Likely shock liver in setting of PEA arrest. RUQUS without any acute pathology on admission. Improved over course of admission given no further ischemic insults. Aorvastatin was held. # Hypertension Was an ongoing issue since admission and discontinuation of sedation. Required nitroglycerin drip to optimize blood pressure control initially, but restarted home anti-hypertensive medications on [MASKED], with subsequent weaning off nitroglycerin drip and resolution of hypertension. Continued carvedilol 25mg BID and amlodipine 5mg daily thereafter. =============== CHRONIC ISSUES: =============== # BPH Continued finasteride 5mg daily and held tamsulosin initially. Discontinued finasteride in setting of Foley use. # GERD IV famotidine in place of home omeprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Ascorbic Acid [MASKED] mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 6. CARVedilol 25 mg PO BID 7. Vitamin D [MASKED] UNIT PO 1X/WEEK (WE) 8. Finasteride 5 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Fleet Enema (Saline) AILY:PRN constipation 12. Tamsulosin 0.8 mg PO QHS 13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Calcitriol 0.25 mcg PO DAILY 16. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 17. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second Line Discharge Medications: pt deceased Discharge Disposition: Expired Discharge Diagnosis: pt deceased Discharge Condition: pt deceased Discharge Instructions: pt deceased Followup Instructions: [MASKED]
[]
[ "J9601", "E872", "I130", "I5032", "Z66", "Z515", "Z87891", "N400", "K219", "Z794", "E785", "E1122", "N189" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "L89153: Pressure ulcer of sacral region, stage 3", "I639: Cerebral infarction, unspecified", "N170: Acute kidney failure with tubular necrosis", "J9601: Acute respiratory failure with hypoxia", "K7201: Acute and subacute hepatic failure with coma", "E872: Acidosis", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "G931: Anoxic brain damage, not elsewhere classified", "I468: Cardiac arrest due to other underlying condition", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "R402433: Glasgow coma scale score 3-8, at hospital admission", "Z87891: Personal history of nicotine dependence", "E875: Hyperkalemia", "E8339: Other disorders of phosphorus metabolism", "R8271: Bacteriuria", "B952: Enterococcus as the cause of diseases classified elsewhere", "D631: Anemia in chronic kidney disease", "Z006: Encounter for examination for normal comparison and control in clinical research program", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I495: Sick sinus syndrome", "R680: Hypothermia, not associated with low environmental temperature", "R569: Unspecified convulsions", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma" ]
10,067,834
25,366,430
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, right hemicolectomy History of Present Illness: ___ is a ___ year-old man with no prior medical history who presented to the ___ ED with 1 day of worsening generalized lower abdominal pain. Sudden onset after he went for a run. Associated with nausea and few episodes of emesis. He reports severe RLQ pain. No passing of flatus or BMs for 24 hours. In the ED, a CT scan demonstrated cecum dilation to 10cm with concern for cecal volvulus. Labs notable for normal WBC and lactic acid levels. Past Medical History: Past Medical History: None Past Surgical History: Hydrocele repair in childhood Social History: ___ Family History: Parents with HLD Physical Exam: Admission Physical Exam: VS: 98.4 70 113/52 16 96% on room air Gen: Extremely uncomfortably appearing CV: RRR Resp: Good air movement bilaterally Abd: Distended, tender to palpation, +guarding Ext: Warm, well-perfused Discharge Physical Exam: VS: T: 98.4 PO BP: 117/69 R Lying HR: 101 RR: 18 O2: 99% Ra GEN: A+Ox3, NAD HEENT: atraumatic CV: RRR PULM: CTA b/l ABD: soft, non-distended, non-tender to palpation. Inferior portion of incision gently packed with gauze with overlying dsd. Steri-strips in place on rest of wound. No s/s infection, wound well-approximated EXT: wwp, no edema b/l Pertinent Results: IMAGING: ___: CT Abdomen/Pelvis: The cecum is dilated up to 10 mm and appears displaced into midline of the abdomen with apparent twisting of the ascending colon at its takeoff. Although there is no dramatic twisting of the mesenteric vessels, these findings raise concern for cecal volvulus. No bowel wall thickening, pneumatosis or free air. Surgical consultation is recommended. LABS: ___ 08:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-300* KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 06:26AM GLUCOSE-170* UREA N-11 CREAT-1.0 SODIUM-139 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-17* ANION GAP-16 ___ 06:26AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.6 ___ 06:26AM WBC-18.4* RBC-4.93 HGB-14.2 HCT-42.0 MCV-85 MCH-28.8 MCHC-33.8 RDW-12.6 RDWSD-39.4 ___ 06:26AM PLT COUNT-287 ___ 06:26AM ___ PTT-23.5* ___ ___ 09:33PM LACTATE-1.6 ___ 04:11PM ___ ___ 03:58PM GLUCOSE-112* UREA N-11 CREAT-0.9 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-18* ANION GAP-18 ___ 03:58PM WBC-8.1 RBC-5.39 HGB-15.4 HCT-44.9 MCV-83 MCH-28.6 MCHC-34.3 RDW-12.7 RDWSD-38.1 ___ 03:58PM NEUTS-77.1* LYMPHS-17.3* MONOS-5.2 EOS-0.1* BASOS-0.1 IM ___ AbsNeut-6.21* AbsLymp-1.40 AbsMono-0.42 AbsEos-0.01* AbsBaso-0.01 ___ 03:58PM PLT COUNT-274 Brief Hospital Course: Mr. ___ is a ___ year-old man with no prior medical history who presented to the ___ ED with 1 day of worsening generalized lower abdominal pain. In the ED, a CT scan demonstrated cecum dilation to 10cm with concern for cecal volvulus. Labs notable for normal WBC and lactic acid levels. The patient was consented for surgery and was taken to the operating room where he underwent right hemicolectomy. This procedure went well (reader, refer to operative note for further details). On POD #0 he was started on sips and then later advanced to clears. Foley was removed on POD #1 and he voided without issue. On POD #3, diet was advanced to regular but was later backed down to clears due to abdominal pain and cramping. On POD #5, abdominal pain improved and he was advanced a regular diet, IVF were discontinued. On POD #6, the inferior portion of the abdominal incision was indurated, thought to be consistent with a seroma or hematoma. This was opened by the surgical team at the bedside which revealed a hematoma without any purulence noted. The wound was gently packed with gauze and covered with a dsd. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever do NOT exceed 4 grams in 24 hours 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: Cecal volvulus 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 were found to have a cecal volvulus which is a condition where a loop of intestine twists around itself, resulting in a bowel obstruction. You were taken to the operating room and had the affected portion of colon removed. Your diet was gradually advanced. You are now tolerating a regular diet and your pain is better controlled. You are now ready to be discharged from the hospital. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. *You may remove the gauze packing from your abdominal incision tomorrow (___) and then cover the wound with dry gauze until the wound begins to dry and scab. Followup Instructions: ___
[ "K562", "K567" ]
Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED]: Exploratory laparotomy, right hemicolectomy History of Present Illness: [MASKED] is a [MASKED] year-old man with no prior medical history who presented to the [MASKED] ED with 1 day of worsening generalized lower abdominal pain. Sudden onset after he went for a run. Associated with nausea and few episodes of emesis. He reports severe RLQ pain. No passing of flatus or BMs for 24 hours. In the ED, a CT scan demonstrated cecum dilation to 10cm with concern for cecal volvulus. Labs notable for normal WBC and lactic acid levels. Past Medical History: Past Medical History: None Past Surgical History: Hydrocele repair in childhood Social History: [MASKED] Family History: Parents with HLD Physical Exam: Admission Physical Exam: VS: 98.4 70 113/52 16 96% on room air Gen: Extremely uncomfortably appearing CV: RRR Resp: Good air movement bilaterally Abd: Distended, tender to palpation, +guarding Ext: Warm, well-perfused Discharge Physical Exam: VS: T: 98.4 PO BP: 117/69 R Lying HR: 101 RR: 18 O2: 99% Ra GEN: A+Ox3, NAD HEENT: atraumatic CV: RRR PULM: CTA b/l ABD: soft, non-distended, non-tender to palpation. Inferior portion of incision gently packed with gauze with overlying dsd. Steri-strips in place on rest of wound. No s/s infection, wound well-approximated EXT: wwp, no edema b/l Pertinent Results: IMAGING: [MASKED]: CT Abdomen/Pelvis: The cecum is dilated up to 10 mm and appears displaced into midline of the abdomen with apparent twisting of the ascending colon at its takeoff. Although there is no dramatic twisting of the mesenteric vessels, these findings raise concern for cecal volvulus. No bowel wall thickening, pneumatosis or free air. Surgical consultation is recommended. LABS: [MASKED] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-300* KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 06:26AM GLUCOSE-170* UREA N-11 CREAT-1.0 SODIUM-139 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-17* ANION GAP-16 [MASKED] 06:26AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.6 [MASKED] 06:26AM WBC-18.4* RBC-4.93 HGB-14.2 HCT-42.0 MCV-85 MCH-28.8 MCHC-33.8 RDW-12.6 RDWSD-39.4 [MASKED] 06:26AM PLT COUNT-287 [MASKED] 06:26AM [MASKED] PTT-23.5* [MASKED] [MASKED] 09:33PM LACTATE-1.6 [MASKED] 04:11PM [MASKED] [MASKED] 03:58PM GLUCOSE-112* UREA N-11 CREAT-0.9 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-18* ANION GAP-18 [MASKED] 03:58PM WBC-8.1 RBC-5.39 HGB-15.4 HCT-44.9 MCV-83 MCH-28.6 MCHC-34.3 RDW-12.7 RDWSD-38.1 [MASKED] 03:58PM NEUTS-77.1* LYMPHS-17.3* MONOS-5.2 EOS-0.1* BASOS-0.1 IM [MASKED] AbsNeut-6.21* AbsLymp-1.40 AbsMono-0.42 AbsEos-0.01* AbsBaso-0.01 [MASKED] 03:58PM PLT COUNT-274 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old man with no prior medical history who presented to the [MASKED] ED with 1 day of worsening generalized lower abdominal pain. In the ED, a CT scan demonstrated cecum dilation to 10cm with concern for cecal volvulus. Labs notable for normal WBC and lactic acid levels. The patient was consented for surgery and was taken to the operating room where he underwent right hemicolectomy. This procedure went well (reader, refer to operative note for further details). On POD #0 he was started on sips and then later advanced to clears. Foley was removed on POD #1 and he voided without issue. On POD #3, diet was advanced to regular but was later backed down to clears due to abdominal pain and cramping. On POD #5, abdominal pain improved and he was advanced a regular diet, IVF were discontinued. On POD #6, the inferior portion of the abdominal incision was indurated, thought to be consistent with a seroma or hematoma. This was opened by the surgical team at the bedside which revealed a hematoma without any purulence noted. The wound was gently packed with gauze and covered with a dsd. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever do NOT exceed 4 grams in 24 hours 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: Cecal volvulus 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 were found to have a cecal volvulus which is a condition where a loop of intestine twists around itself, resulting in a bowel obstruction. You were taken to the operating room and had the affected portion of colon removed. Your diet was gradually advanced. You are now tolerating a regular diet and your pain is better controlled. You are now ready to be discharged from the hospital. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. *You may remove the gauze packing from your abdominal incision tomorrow ([MASKED]) and then cover the wound with dry gauze until the wound begins to dry and scab. Followup Instructions: [MASKED]
[]
[]
[ "K562: Volvulus", "K567: Ileus, unspecified" ]
10,067,834
29,802,622
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ swelling and pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year-old man who is ___ s/p open right hemicolectomy for cecal volvulus who presents to with ___ swelling and pain with persistent bloody drainage from the inferior aspect of wound. He recently completed a course of Keflex for suspected surgical site infection and was re-evaluated in clinic 3 days ago with a plan to continue ___ with daily packing. He presents today with persistent concern for swelling at the area and pain during ___ dressing changes. He has stopped taking pain medications including Tylenol. He denies fever or chills. He reports he ate a salad for the first time and felt nauseas & vomited after, otherwise he has been tolerating a regular diet without issues. He is passing flatus and having non-bloody bowel movements. Past Medical History: Past Medical History: Mono Cecal volvulus Past Surgical History: Ex-lap, right hemicolectomy Hydrocele repair during childhood Social History: ___ Family History: noncontributory Physical Exam: Physical Exam: VS: 98.9 95 18 113/57 99% RA Gen: NAD, A&Ox3, pleasant, conversant CV: Regular rate and rhythm Resp: No increased work of breathing Abd: Soft, minimally distended, mild ___ tenderness. Midline wound without surrounding erythema, 4 mm incisional opening packed with wick, removed with expressible thin sanguinous fluid without purulence. A thin firm ovoid mass approx. 1 inch in vertical dimension is palpated just below the skin at the inferior aspect of the wound likely representing an old organized small hematoma. Ext: Warm, well-perfused, no edema Discharge Physical Exam: VS: 97.7, 103/65, 79, 18, 100 Ra Gen: A&O x3. sitting up in bed in NAD CV: ___ normal SR Pulm: LS ctab Abd: soft, NT/ND. Inferior aspect of midline incision with pinhole opening and scant thin purulent drainage, lightly packed with wick. Pertinent Results: CT A/P ___ 1. 4.4 cm peripherally enhancing pelvic fluid collection posterior to the bladder and anterior to the sigmoid colon concerning for abscess. 2. Fat stranding in the right upper quadrant around the ileocolic anastomosis may be postsurgical. No extraluminal contrast to suggest anastomotic leak. LABS: ___ 03:32PM GLUCOSE-111* UREA N-7 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13 ___ 03:32PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-1.9 ___ 03:32PM WBC-8.1 RBC-4.26* HGB-12.4* HCT-37.3* MCV-88 MCH-29.1 MCHC-33.2 RDW-12.6 RDWSD-40.2 ___ 03:32PM PLT COUNT-380 ___ 09:07PM GLUCOSE-92 UREA N-13 CREAT-1.0 SODIUM-141 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 ___ 09:07PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-68 TOT BILI-0.2 ___ 09:07PM LIPASE-175* ___ 09:07PM ALBUMIN-4.1 ___ 09:07PM WBC-9.3 RBC-4.05* HGB-11.6* HCT-35.7* MCV-88 MCH-28.6 MCHC-32.5 RDW-12.6 RDWSD-40.7 ___ 09:07PM NEUTS-59.5 ___ MONOS-6.3 EOS-1.2 BASOS-0.4 IM ___ AbsNeut-5.55 AbsLymp-3.00 AbsMono-0.59 AbsEos-0.11 AbsBaso-0.04 ___ 09:07PM PLT COUNT-427* Brief Hospital Course: Mr. ___ is a ___ year old male who has a recently history of a right hemicolectomy on ___ for cecal volvulus now presenting with incisional pain and drainage with imaging consistent with a 4 cm pelvic abscess. After discussing options with the patient and his father, the decision was made to treat this with antibiotics. He was admitted to the surgical service for management. He was started on IV ciprofloxacin and flagyl and transitioned to oral antibiotics once tolerating a regular diet. At the time of discharge, he was afebrile and hemodynamically stable, he was tolerating a regular diet, ambulating without assistance, pain was well controlled on oral medication, and he was voiding adequately and spontaneously. He was discharged home with oral antibiotics and appropriately outpatient followup. He resumed ___ services for wound care. He verbalized understanding with the plan. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ciprofloxacin HCl 500 mg PO BID Last dose on ___ RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*17 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*26 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Abdominal abscess 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 drainage at your incision and abdominal pain. You underwent a CT scan which showed you have a 4cm pelvic abscess. You were started on antibiotics, and will follow-up in 10 days with a repeat CT scan to see if the abscess has resolved. You are now being discharged home to continue your recovery with the following instructions. You will be given a prescription to complete 10 days of antibiotics. Please follow up in the Acute Care Surgery clinic at the appointment listed below. 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. Best Wishes, Your ___ Surgery Team Followup Instructions: ___
[ "T8143XA", "T8189XA", "R109" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] swelling and pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] year-old man who is [MASKED] s/p open right hemicolectomy for cecal volvulus who presents to with [MASKED] swelling and pain with persistent bloody drainage from the inferior aspect of wound. He recently completed a course of Keflex for suspected surgical site infection and was re-evaluated in clinic 3 days ago with a plan to continue [MASKED] with daily packing. He presents today with persistent concern for swelling at the area and pain during [MASKED] dressing changes. He has stopped taking pain medications including Tylenol. He denies fever or chills. He reports he ate a salad for the first time and felt nauseas & vomited after, otherwise he has been tolerating a regular diet without issues. He is passing flatus and having non-bloody bowel movements. Past Medical History: Past Medical History: Mono Cecal volvulus Past Surgical History: Ex-lap, right hemicolectomy Hydrocele repair during childhood Social History: [MASKED] Family History: noncontributory Physical Exam: Physical Exam: VS: 98.9 95 18 113/57 99% RA Gen: NAD, A&Ox3, pleasant, conversant CV: Regular rate and rhythm Resp: No increased work of breathing Abd: Soft, minimally distended, mild [MASKED] tenderness. Midline wound without surrounding erythema, 4 mm incisional opening packed with wick, removed with expressible thin sanguinous fluid without purulence. A thin firm ovoid mass approx. 1 inch in vertical dimension is palpated just below the skin at the inferior aspect of the wound likely representing an old organized small hematoma. Ext: Warm, well-perfused, no edema Discharge Physical Exam: VS: 97.7, 103/65, 79, 18, 100 Ra Gen: A&O x3. sitting up in bed in NAD CV: [MASKED] normal SR Pulm: LS ctab Abd: soft, NT/ND. Inferior aspect of midline incision with pinhole opening and scant thin purulent drainage, lightly packed with wick. Pertinent Results: CT A/P [MASKED] 1. 4.4 cm peripherally enhancing pelvic fluid collection posterior to the bladder and anterior to the sigmoid colon concerning for abscess. 2. Fat stranding in the right upper quadrant around the ileocolic anastomosis may be postsurgical. No extraluminal contrast to suggest anastomotic leak. LABS: [MASKED] 03:32PM GLUCOSE-111* UREA N-7 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13 [MASKED] 03:32PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-1.9 [MASKED] 03:32PM WBC-8.1 RBC-4.26* HGB-12.4* HCT-37.3* MCV-88 MCH-29.1 MCHC-33.2 RDW-12.6 RDWSD-40.2 [MASKED] 03:32PM PLT COUNT-380 [MASKED] 09:07PM GLUCOSE-92 UREA N-13 CREAT-1.0 SODIUM-141 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 [MASKED] 09:07PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-68 TOT BILI-0.2 [MASKED] 09:07PM LIPASE-175* [MASKED] 09:07PM ALBUMIN-4.1 [MASKED] 09:07PM WBC-9.3 RBC-4.05* HGB-11.6* HCT-35.7* MCV-88 MCH-28.6 MCHC-32.5 RDW-12.6 RDWSD-40.7 [MASKED] 09:07PM NEUTS-59.5 [MASKED] MONOS-6.3 EOS-1.2 BASOS-0.4 IM [MASKED] AbsNeut-5.55 AbsLymp-3.00 AbsMono-0.59 AbsEos-0.11 AbsBaso-0.04 [MASKED] 09:07PM PLT COUNT-427* Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male who has a recently history of a right hemicolectomy on [MASKED] for cecal volvulus now presenting with incisional pain and drainage with imaging consistent with a 4 cm pelvic abscess. After discussing options with the patient and his father, the decision was made to treat this with antibiotics. He was admitted to the surgical service for management. He was started on IV ciprofloxacin and flagyl and transitioned to oral antibiotics once tolerating a regular diet. At the time of discharge, he was afebrile and hemodynamically stable, he was tolerating a regular diet, ambulating without assistance, pain was well controlled on oral medication, and he was voiding adequately and spontaneously. He was discharged home with oral antibiotics and appropriately outpatient followup. He resumed [MASKED] services for wound care. He verbalized understanding with the plan. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ciprofloxacin HCl 500 mg PO BID Last dose on [MASKED] RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*17 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*26 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Abdominal abscess 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 drainage at your incision and abdominal pain. You underwent a CT scan which showed you have a 4cm pelvic abscess. You were started on antibiotics, and will follow-up in 10 days with a repeat CT scan to see if the abscess has resolved. You are now being discharged home to continue your recovery with the following instructions. You will be given a prescription to complete 10 days of antibiotics. Please follow up in the Acute Care Surgery clinic at the appointment listed below. 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. Best Wishes, Your [MASKED] Surgery Team Followup Instructions: [MASKED]
[]
[]
[ "T8143XA: Infection following a procedure, organ and space surgical site, initial encounter", "T8189XA: Other complications of procedures, not elsewhere classified, initial encounter", "R109: Unspecified abdominal pain" ]
10,067,859
23,242,113
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: mid lower back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ w/ hx of Crohn's and symptomatic enlarging AAA s/p EVAR ___ who is presenting w/ a ~2 day hx of aching mid lower back pain radiating to L inguinal region that has not worsened or improved. He was being seen today by a general surgeon for evaluation of his R inguinal hernia, and was told to come to OSH ED, where a CTA was done showing a type 2 endoleak likely from ___ or a lumbar artery. He was txfr'ed here to the ED for further management, and we were consulted. Past Medical History: Crohn's colitis AAA Appendectomy Social History: ___ Family History: No ___ of Crohns or UC, father with colon ca at age of ___ Physical Exam: Physical Exam At Discharge: Vitals: 98.2, 147/89, 83, 18, 95Ra Gen - no acute distress CV - regular rate and rhythm Pulm - breathing comfortably on room air Abd - soft, nondistended MSK: no leg swelling observed b/l Pulses: R: p//p/p, L: p//p/p Pertinent Results: ___ 04:55AM BLOOD WBC-9.4 RBC-4.02* Hgb-11.1* Hct-34.2* MCV-85 MCH-27.6 MCHC-32.5 RDW-12.9 RDWSD-40.2 Plt ___ ___ 04:45PM BLOOD WBC-12.5* RBC-4.21* Hgb-11.6* Hct-35.8* MCV-85 MCH-27.6 MCHC-32.4 RDW-12.8 RDWSD-39.8 Plt ___ ___ 04:55AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-142 K-3.9 Cl-102 HCO3-25 AnGap-15 ___ 04:45PM BLOOD Glucose-112* UreaN-11 Creat-0.6 Na-142 K-4.1 Cl-102 HCO3-26 AnGap-14 Outside hospital imaging reviewed Brief Hospital Course: Mr. ___ is a ___ year old male with a past medical history of Crohn's and symptomatic enlarging AAA s/p EVAR ___ who presented with back pain radiating to L inguinal region w/ type 2 endoleak on CTA. He was admitted overnight for observation. his abdominal/back pain had improved in the morning. He was not interested in an inguinal hernia repair, but will follow-up with the acute care service in the future if he desires intervention. On hospital day 2 he 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. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: 1. Aspirin EC 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*18 Capsule Refills:*0 3. Simvastatin 20 mg PO QPM RX *simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Mesalamine 1000 mg PO QID 5. PredniSONE 10 mg PO DAILY Discharge Medications: no new medications - see above Discharge Disposition: Home Discharge Diagnosis: type II endoleak sp EVAR Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted overnight for observation for back pain second to an endoleak type II of your AAA repair. You were deemed stable by your healthcare team and are now ready for discharge. MEDICATIONS: • Please continue all medications you were on prior to admission. • You do not need to take any new medications and were not given any new prescriptions. • Please talk to your primary care physician about starting ___ statin, which will help lower your cholesterol and future risks. CALL THE OFFICE FOR : ___ • Redness that extends away from your prior incision • A sudden increase in pain that is not controlled with pain medication • A sudden change in the ability to move or use your leg or the ability to feel your leg • Temperature greater than 101.5F for 24 hours • Bleeding from incision • New or increased drainage from incision or white, yellow or green drainage from incisions We wish you a speedy recovery and a very happy Thanksgiving! Followup Instructions: ___
[ "T82330A", "Y831", "Y929", "K4090", "Z87891", "E669", "Z6841", "K5090" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: mid lower back pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] w/ hx of Crohn's and symptomatic enlarging AAA s/p EVAR [MASKED] who is presenting w/ a ~2 day hx of aching mid lower back pain radiating to L inguinal region that has not worsened or improved. He was being seen today by a general surgeon for evaluation of his R inguinal hernia, and was told to come to OSH ED, where a CTA was done showing a type 2 endoleak likely from [MASKED] or a lumbar artery. He was txfr'ed here to the ED for further management, and we were consulted. Past Medical History: Crohn's colitis AAA Appendectomy Social History: [MASKED] Family History: No [MASKED] of Crohns or UC, father with colon ca at age of [MASKED] Physical Exam: Physical Exam At Discharge: Vitals: 98.2, 147/89, 83, 18, 95Ra Gen - no acute distress CV - regular rate and rhythm Pulm - breathing comfortably on room air Abd - soft, nondistended MSK: no leg swelling observed b/l Pulses: R: p//p/p, L: p//p/p Pertinent Results: [MASKED] 04:55AM BLOOD WBC-9.4 RBC-4.02* Hgb-11.1* Hct-34.2* MCV-85 MCH-27.6 MCHC-32.5 RDW-12.9 RDWSD-40.2 Plt [MASKED] [MASKED] 04:45PM BLOOD WBC-12.5* RBC-4.21* Hgb-11.6* Hct-35.8* MCV-85 MCH-27.6 MCHC-32.4 RDW-12.8 RDWSD-39.8 Plt [MASKED] [MASKED] 04:55AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-142 K-3.9 Cl-102 HCO3-25 AnGap-15 [MASKED] 04:45PM BLOOD Glucose-112* UreaN-11 Creat-0.6 Na-142 K-4.1 Cl-102 HCO3-26 AnGap-14 Outside hospital imaging reviewed Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with a past medical history of Crohn's and symptomatic enlarging AAA s/p EVAR [MASKED] who presented with back pain radiating to L inguinal region w/ type 2 endoleak on CTA. He was admitted overnight for observation. his abdominal/back pain had improved in the morning. He was not interested in an inguinal hernia repair, but will follow-up with the acute care service in the future if he desires intervention. On hospital day 2 he 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. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. Medications on Admission: 1. Aspirin EC 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*18 Capsule Refills:*0 3. Simvastatin 20 mg PO QPM RX *simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Mesalamine 1000 mg PO QID 5. PredniSONE 10 mg PO DAILY Discharge Medications: no new medications - see above Discharge Disposition: Home Discharge Diagnosis: type II endoleak sp EVAR 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 overnight for observation for back pain second to an endoleak type II of your AAA repair. You were deemed stable by your healthcare team and are now ready for discharge. MEDICATIONS: • Please continue all medications you were on prior to admission. • You do not need to take any new medications and were not given any new prescriptions. • Please talk to your primary care physician about starting [MASKED] statin, which will help lower your cholesterol and future risks. CALL THE OFFICE FOR : [MASKED] • Redness that extends away from your prior incision • A sudden increase in pain that is not controlled with pain medication • A sudden change in the ability to move or use your leg or the ability to feel your leg • Temperature greater than 101.5F for 24 hours • Bleeding from incision • New or increased drainage from incision or white, yellow or green drainage from incisions We wish you a speedy recovery and a very happy Thanksgiving! Followup Instructions: [MASKED]
[]
[ "Y929", "Z87891", "E669" ]
[ "T82330A: Leakage of aortic (bifurcation) graft (replacement), initial encounter", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent", "Z87891: Personal history of nicotine dependence", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "K5090: Crohn's disease, unspecified, without complications" ]
10,067,859
23,598,978
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Symptomatic enlarging Abdominal Aortic Aneurysm with dissection flap Major Surgical or Invasive Procedure: ___: Endovascular Aortic Aneurysm Repair History of Present Illness: ___ is a ___ w/ hx of Crohn's disease and AAA who is presenting as a txf'r from ___ w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at ___ and was started on an esmolol gtt. Past Medical History: Crohn's colitis AAA Appendectomy Social History: ___ Family History: No FMH of Crohns or UC, father with colon ca at age of ___ Physical Exam: Phys Ex: VS - 98.1 82 129/87 16 95% RA Gen - NAD CV - RRR, palpable b/l ___ & DP pulses Pulm - non-labored breathing, no resp distress Abd - obese, soft, nondistended, mild LLQ ttp w/ no guarding or rebound MSK & extremities/skin - no leg swelling observed b/l Pertinent Results: Pertinent Admission Labs: ___ 04:02PM BLOOD WBC-11.8* RBC-4.79# Hgb-13.4*# Hct-40.8# MCV-85 MCH-28.0 MCHC-32.8 RDW-13.2 RDWSD-41.4 Plt ___ ___ 04:02PM BLOOD Neuts-81.3* Lymphs-11.2* Monos-6.7 Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.60*# AbsLymp-1.32 AbsMono-0.79 AbsEos-0.00* AbsBaso-0.04 ___ 04:02PM BLOOD Plt ___ ___ 04:02PM BLOOD Glucose-121* UreaN-16 Creat-0.6 Na-139 K-4.4 Cl-101 HCO3-22 AnGap-16 ___ 04:02PM BLOOD ALT-12 AST-18 AlkPhos-58 TotBili-0.3 ___ 04:02PM BLOOD Lipase-42 ___ 04:02PM BLOOD cTropnT-<0.01 ___ 04:02PM BLOOD Albumin-4.0 ___ 04:10PM BLOOD Lactate-1.4 Pertinent Discharge Labs: ___ 05:46PM BLOOD Hct-36.9* ___ 04:24PM BLOOD Neuts-79.8* Lymphs-12.0* Monos-7.5 Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.74* AbsLymp-1.31 AbsMono-0.82* AbsEos-0.00* AbsBaso-0.03 ___ 04:24PM BLOOD Plt ___ ___ 03:13AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-24 AnGap-13 ___ 04:24PM BLOOD ALT-13 AST-33 AlkPhos-55 TotBili-0.4 ___ 04:24PM BLOOD Lipase-46 ___ 10:10PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 03:13AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7 Imaging: FEMORAL VASCULAR US LEFT ___ IMPRESSION: Normal sonographic appearance of the groin, without evidence of hematoma, pseudoaneurysm, or AV fistula. Brief Hospital Course: ___ is a ___ w/ hx of Crohn's disease and AAA who is presenting as a txf'r from ___ w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at ___ and was started on an esmolol gtt. Patient was taken urgently to OR for EVAR procedure for symptomatic/dissected infrarenal AAA. For the details of the procedure, please see the surgeon's operative note. He received ___ antibiotics. He was admitted to the ___ on ___ post-operatively. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well. He 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. Patient did have a little burning on urination that resolved spontaneously and some tenderness to his left groin incision site. Patient had a urinalysis sent and an ultrasound taken of his left groin. Both tests came back negative for any concerning findings. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. He will follow up with Dr. ___ in 1 month with a CTA. Medications on Admission: -Humira -Prednisone 10 mg PO DAILY -Other medication unable to remember name ___: 1. ___ EC 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*18 Capsule Refills:*0 3. Simvastatin 20 mg PO QPM RX *simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Mesalamine 1000 mg PO QID 5. PredniSONE 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis/es 1. Dissected infrarenal abdominal aortic aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions MEDICATIONS: •Take Aspirin 325mg (enteric coated) once daily •Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. •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 AT HOME: It is normal to have slight swelling of the legs: •Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 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 go up and down 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 that is draining, as needed •No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) •After 1 week, you may resume sexual activity •After 1 week, gradually increase your activities and distance walked as you can tolerate •No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ •Numbness, coldness or pain in lower extremities •Temperature greater than 101.5F for 24 hours •New or increased drainage from incision or white, yellow or green drainage from incisions •Bleeding from groin puncture site FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •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: ___
[ "I7102", "K5090", "Z87891", "E669", "Z6836" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Symptomatic enlarging Abdominal Aortic Aneurysm with dissection flap Major Surgical or Invasive Procedure: [MASKED]: Endovascular Aortic Aneurysm Repair History of Present Illness: [MASKED] is a [MASKED] w/ hx of Crohn's disease and AAA who is presenting as a txf'r from [MASKED] w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at [MASKED] and was started on an esmolol gtt. Past Medical History: Crohn's colitis AAA Appendectomy Social History: [MASKED] Family History: No FMH of Crohns or UC, father with colon ca at age of [MASKED] Physical Exam: Phys Ex: VS - 98.1 82 129/87 16 95% RA Gen - NAD CV - RRR, palpable b/l [MASKED] & DP pulses Pulm - non-labored breathing, no resp distress Abd - obese, soft, nondistended, mild LLQ ttp w/ no guarding or rebound MSK & extremities/skin - no leg swelling observed b/l Pertinent Results: Pertinent Admission Labs: [MASKED] 04:02PM BLOOD WBC-11.8* RBC-4.79# Hgb-13.4*# Hct-40.8# MCV-85 MCH-28.0 MCHC-32.8 RDW-13.2 RDWSD-41.4 Plt [MASKED] [MASKED] 04:02PM BLOOD Neuts-81.3* Lymphs-11.2* Monos-6.7 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-9.60*# AbsLymp-1.32 AbsMono-0.79 AbsEos-0.00* AbsBaso-0.04 [MASKED] 04:02PM BLOOD Plt [MASKED] [MASKED] 04:02PM BLOOD Glucose-121* UreaN-16 Creat-0.6 Na-139 K-4.4 Cl-101 HCO3-22 AnGap-16 [MASKED] 04:02PM BLOOD ALT-12 AST-18 AlkPhos-58 TotBili-0.3 [MASKED] 04:02PM BLOOD Lipase-42 [MASKED] 04:02PM BLOOD cTropnT-<0.01 [MASKED] 04:02PM BLOOD Albumin-4.0 [MASKED] 04:10PM BLOOD Lactate-1.4 Pertinent Discharge Labs: [MASKED] 05:46PM BLOOD Hct-36.9* [MASKED] 04:24PM BLOOD Neuts-79.8* Lymphs-12.0* Monos-7.5 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-8.74* AbsLymp-1.31 AbsMono-0.82* AbsEos-0.00* AbsBaso-0.03 [MASKED] 04:24PM BLOOD Plt [MASKED] [MASKED] 03:13AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-24 AnGap-13 [MASKED] 04:24PM BLOOD ALT-13 AST-33 AlkPhos-55 TotBili-0.4 [MASKED] 04:24PM BLOOD Lipase-46 [MASKED] 10:10PM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 03:13AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7 Imaging: FEMORAL VASCULAR US LEFT [MASKED] IMPRESSION: Normal sonographic appearance of the groin, without evidence of hematoma, pseudoaneurysm, or AV fistula. Brief Hospital Course: [MASKED] is a [MASKED] w/ hx of Crohn's disease and AAA who is presenting as a txf'r from [MASKED] w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at [MASKED] and was started on an esmolol gtt. Patient was taken urgently to OR for EVAR procedure for symptomatic/dissected infrarenal AAA. For the details of the procedure, please see the surgeon's operative note. He received [MASKED] antibiotics. He was admitted to the [MASKED] on [MASKED] post-operatively. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well. He 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. Patient did have a little burning on urination that resolved spontaneously and some tenderness to his left groin incision site. Patient had a urinalysis sent and an ultrasound taken of his left groin. Both tests came back negative for any concerning findings. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. He will follow up with Dr. [MASKED] in 1 month with a CTA. Medications on Admission: -Humira -Prednisone 10 mg PO DAILY -Other medication unable to remember name [MASKED]: 1. [MASKED] EC 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*18 Capsule Refills:*0 3. Simvastatin 20 mg PO QPM RX *simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Mesalamine 1000 mg PO QID 5. PredniSONE 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis/es 1. Dissected infrarenal abdominal aortic aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions MEDICATIONS: •Take Aspirin 325mg (enteric coated) once daily •Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. •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 AT HOME: It is normal to have slight swelling of the legs: •Elevate your leg above the level of your heart (use [MASKED] pillows or a recliner) every [MASKED] hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 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 go up and down 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 that is draining, as needed •No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) •After 1 week, you may resume sexual activity •After 1 week, gradually increase your activities and distance walked as you can tolerate •No driving until you are no longer taking pain medications CALL THE OFFICE FOR: [MASKED] •Numbness, coldness or pain in lower extremities •Temperature greater than 101.5F for 24 hours •New or increased drainage from incision or white, yellow or green drainage from incisions •Bleeding from groin puncture site FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •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 [MASKED] for transfer to closest Emergency Room. Followup Instructions: [MASKED]
[]
[ "Z87891", "E669" ]
[ "I7102: Dissection of abdominal aorta", "K5090: Crohn's disease, unspecified, without complications", "Z87891: Personal history of nicotine dependence", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]
10,067,859
28,304,238
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: ___ Sigmoidoscopy ___ Sigmoidoscopy History of Present Illness: ___ M h/o Crohn's ___ years, with PMH of AAA and appendectomy, admitted to ___ on ___ for significant abdominal pain found to be consistent with a Crohn's flare. Approximately 2 weeks ago he was admitted to ___ for Crohn's flare, hospitalized for 1 week and discharged on PO prednisone and mesalamine. He reports previously being on prednisone with excellent control of his Crohn's that was diagnosed ___ years ago. At home, his symptoms did not improve and he noted worsening LLQ abd pain, diarrhea, so he represented to ___. CT abd/pel showed rectosigmoid colitis, focal wall thickening in hepatic flexure and distention in transverse colon. CRP 15, ESR 84. He received Mesalamine 2.4g q12h and IV Solumedrol 60mg q6h. Due to continued symptoms, he had a colonoscopy done on ___ - showing severe Crohn's: extensive ulceration without signs of bleeding, diffuse inflammation throughout the colon (significant at rectosigmoid region), no masses, biopsies pending. Due to inability to take any POs, he received a PICC and is on TPN with lipids. He is on IV morphine for pain. Patient had worsening abdominal pain and rectal bleeding. GI is also recommended Humira (or biologics) - but reportedly the hospital does not have this medication. He is being transferred to ___ for continued management of Crohn's flare and advanced level of care should he require GI surgery. Past Medical History: Crohn's colitis AAA Appendectomy Social History: ___ Family History: No FMH of Crohns or UC, father with colon ca at age of ___ Physical Exam: Admission Physical Exam: VITALS: 98.0 PO 119 / 72 67 19 99 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, hyperactive bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, normal gait Discharge physical exam: 97.8 PO 120 / 75 80 18 99 RA General: NAD, well-developed, sitting up in chair comfortably, AOX3 CV: RRR, normal S1 + S2, no m/g/r appreciated Lungs: CTAB, no wheezes, rales, rhonchi, crackles Abdomen: NABS, Soft, NTND, no rebound or guarding Ext: Pulses present, no pitting edema present Neuro: CNII-XII intact, no motor/sensory deficits elicited Pertinent Results: Admission labs: ================= ___ 02:12AM BLOOD WBC-7.3 RBC-3.68* Hgb-10.0* Hct-30.7* MCV-83 MCH-27.2 MCHC-32.6 RDW-13.6 RDWSD-40.8 Plt ___ ___ 02:12AM BLOOD Neuts-87* Bands-5 Lymphs-2* Monos-5 Eos-0 Baso-1 ___ Myelos-0 AbsNeut-6.72* AbsLymp-0.15* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.07 ___ 02:12AM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-135 K-4.3 Cl-97 HCO3-25 AnGap-13 ___ 02:12AM BLOOD ALT-56* AST-37 LD(LDH)-115 AlkPhos-61 Amylase-26 TotBili-0.3 ___ 02:12AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.5 Mg-2.1 Iron-65 ___ 02:12AM BLOOD calTIBC-202* VitB12-936* Ferritn-93 TRF-155* ___ 02:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 02:12AM BLOOD CRP-8.7* ___ 02:12AM BLOOD HIV Ab-NEG ___ 02:12AM BLOOD HCV Ab-POS* ___ 02:12AM BLOOD HCV VL-NOT DETECT ___ 06:35PM BLOOD Lactate-2.1* ================ Discharge Labs: =================== ___ 06:12AM BLOOD WBC-13.6* RBC-3.42* Hgb-9.5* Hct-29.1* MCV-85 MCH-27.8 MCHC-32.6 RDW-16.3* RDWSD-47.9* Plt ___ ___ 06:12AM BLOOD Glucose-124* UreaN-20 Creat-0.5 Na-137 K-4.5 Cl-100 HCO3-23 AnGap-14 ___ 06:12AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0 ___ 05:22AM BLOOD CRP-1.0 =============== Imaging: =============== ___ CT Abdomen: There is massive dilatation of the transverse colon measuring up to 13.7 cm. This is similar to slightly progressed when compared to the prior study. The presence of air in the descending colon and rectum makes mechanical obstruction less likely. There is bowel wall edema evident in the descending colon consistent with the findings on the prior CT. There is loss of normal haustra pattern within the massively distended transverse colon. Toxic megacolon cannot be excluded however the time course with stability over a 6 day period is not typical. No free air seen. ___ CXR (TB screen): The tip of the PICC projects over the distal SVC. There is no focal consolidation. There is no pleural effusion. The trachea is midline. The aorta is atherosclerotic and tortuous. Degenerative changes are evident in the spine. ___ MRE enterography: 1. Active inflammation involving an approximately 8.0 cm segment of sigmoid colon, with wall thickening and pericolonic vascular prominence. 2. Subacute inflammation involving the rectum. Please note that the anal canal was not included on this examination. 3. Ahaustral dilated transverse colon and ahaustral nondilated descending colon, suggesting chronic inflammation. Focal narrowed caliber of the proximal transverse colon with the lumen measuring 1.3 cm, similar to prior CT. 4. No evidence of small bowel inflammation. 5. Fusiform 4.9 cm infrarenal abdominal aortic aneurysm. 6. Small bowel containing right inguinal hernia. No evidence of obstruction. ========== Micro: ========== ___ Cdiff: Positive ___ Stool culture: FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Path: ___ rectal biopsy: 1. Rectum, biopsy: - Severe chronic active colitis with ulceration. - No granulomata or dysplasia identified. - Immunostain for CMV is negative. ___ Rectal biopsy: Active colitis with ulceration ; granulomas or dysplasia not identified. Brief Hospital Course: ___ M HCV-Ab positive, with Crohn's (on mesalamine and prednisone at home), readmitted to OSH for Crohns flare (received IV solumedrol and mesalamine, s/p colonoscopy), and transferred to ___ for management of Crohns flare. #Crohn's flare- Presented with abdominal distension and diarrhea. Colonoscopy at OSH showed extensive ulcerative disease with path showing chronic active colitis. CT on admission showed rectosigmoid colitis, hepatic flexure inflammation and transverse colon distension. KUB with ~13cm distension of transverse colon. Evaluated by colorectal surgery without need for surgical intervention. Crohn's flare managed by IV solumedrom 20mg Q8hr. Flex sig showed inflammatory colitis and was negative for CMV colitis. Daily KUB and CRP showed improvement of colonic distension with CRP downtrending to 1.0. Attempted to obtain Humira but due to insurance issues was started on Remicaide with first dose on ___ at 10mg/kg after screening evaluation for TB. Patient had no TB risk factors with negative CXR but quantiferon indeterminate given likely anergy from steroids. Diarrhea resolved and no longer blood in stool with stable H/H. He was on bowel rest with TPN with advancement to regular diet by discharge. Started on Prednisone 60mg prior to discharge with plan for taper down to 40mg after 5 days and continued taper per primary GI doctor, ___. Dr. ___ was contacted and confirmed ability to continue Remicaide infusion outpatient in 2 weeks (___) Plan is for next remicade dose at 2 weeks after initial, 5mg/kg, followed by another dose 4 weeks after that (6 weeks after first dose), then 5mg/kg every 8 weeks, with titration based on drug levels and clinical response. #C.diff Colitis- Bloody diarrhea on admission with negative stool cultures and positive for c.diff. Started on PO vanc and IV flagyl with resolution of diarrhea and bloody BM. Iv flagyl stopped on ___ and patient was continued on PO vanc with plan for a total of 14 day course (___) #cleared HCV- On screening prior to administration of Remicaide, he was found to be HCV ab positive with undetectable viral load. No risk factors or blood transfusions. Also was found to not be immunized for Hep B. Follow up with PCP for routine and immmunization for hep B. # AAA - CT scan reported mild interval enlargement of AAA but remained less than <5.5 cm with no symptoms or other concerning findings. Will follow up with PCP for close following and interval imaging. ======================= TRANSITIONAL ISSUES: ======================= MEDICATIONS: - New Meds: PO Vancomycin, Remicaide - Stopped Meds: None (mesalimine held) - Changed Meds: Prednisone 60mg FOLLOW-UP - Follow up: PCP, GI - ___ required after discharge: Immunization for Hep B, monitoring of signs of cirrhosis given Hep C positive - Incidental findings: Not immunized for Hepatitis B - Follow up for management of AAA, 4.9 cm during this admission - Initial Remicaide dose on ___. Plan is for next remicade dose at 2 weeks after initial, 5mg/kg, followed by another dose 4 weeks after that (6 weeks after first dose), then 5mg/kg every 8 weeks, with titration based on drug levels and clinical response. - Continue PO Vanc for 14 day course for C.diff (end on ___ OTHER ISSUES: # CONTACT:Wife ___ ___ # CODE: Full (confirmed) >30 min were spent on dc related activities Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apriso (mesalamine) 1.5 Gram oral DAILY 2. PredniSONE 60 mg PO DAILY 3. LOPERamide 2 mg PO TID:PRN Diarrhea Discharge Medications: 1. DICYCLOMine 10 mg PO TID RX *dicyclomine 10 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 2. PredniSONE 40 mg PO DAILY Start taking on ___ after completing 60 mg RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*75 Tablet Refills:*0 3. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*12 Capsule Refills:*0 4. Apriso (mesalamine) 1.5 Gram oral DAILY 5. LOPERamide 2 mg PO TID:PRN Diarrhea Please do not take this medication while you have active c.diff and are under treatment for it 6. PredniSONE 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Crohn's flare Secondary diagnoses: Clostridum difficile colitis Severe Malnutrition Megacolon Abdominal Aortic aneurysm Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ because you had increased abdominal pain and diarrhea. You were found to have a Crohn's flare with significant distension of your colon and infection of your colon with a bacteria called Clostridium difficile. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - Started on IV steroids - Given nutrition through IV to give your gut some rest - Had scopes done by GI to evaluate your colon inflammation - Give antibiotics (Vancomycin) for treatment of C.diff - Started on Remicaide for treatment of Crohn's flare - Changed IV steroids to pills - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with Dr. ___ a week to schedule your next Remicaide infusion (1st dose on ___ and next due 2 weeks after on ___ - Please follow up with your primary care doctor and other health care providers (see below) - Please take all of your medications as prescribed (see below). - Seek medical attention if you have diarrhea, bloody stools, abdominal distension, increased abdominal pain, fever or other symptoms of concern. Followup Instructions: ___
[ "K50118", "E43", "A047", "Z6836", "I714", "Z87891", "Z800", "R740", "D500", "R739", "T380X5A", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: [MASKED] Sigmoidoscopy [MASKED] Sigmoidoscopy History of Present Illness: [MASKED] M h/o Crohn's [MASKED] years, with PMH of AAA and appendectomy, admitted to [MASKED] on [MASKED] for significant abdominal pain found to be consistent with a Crohn's flare. Approximately 2 weeks ago he was admitted to [MASKED] for Crohn's flare, hospitalized for 1 week and discharged on PO prednisone and mesalamine. He reports previously being on prednisone with excellent control of his Crohn's that was diagnosed [MASKED] years ago. At home, his symptoms did not improve and he noted worsening LLQ abd pain, diarrhea, so he represented to [MASKED]. CT abd/pel showed rectosigmoid colitis, focal wall thickening in hepatic flexure and distention in transverse colon. CRP 15, ESR 84. He received Mesalamine 2.4g q12h and IV Solumedrol 60mg q6h. Due to continued symptoms, he had a colonoscopy done on [MASKED] - showing severe Crohn's: extensive ulceration without signs of bleeding, diffuse inflammation throughout the colon (significant at rectosigmoid region), no masses, biopsies pending. Due to inability to take any POs, he received a PICC and is on TPN with lipids. He is on IV morphine for pain. Patient had worsening abdominal pain and rectal bleeding. GI is also recommended Humira (or biologics) - but reportedly the hospital does not have this medication. He is being transferred to [MASKED] for continued management of Crohn's flare and advanced level of care should he require GI surgery. Past Medical History: Crohn's colitis AAA Appendectomy Social History: [MASKED] Family History: No FMH of Crohns or UC, father with colon ca at age of [MASKED] Physical Exam: Admission Physical Exam: VITALS: 98.0 PO 119 / 72 67 19 99 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, hyperactive bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, normal gait Discharge physical exam: 97.8 PO 120 / 75 80 18 99 RA General: NAD, well-developed, sitting up in chair comfortably, AOX3 CV: RRR, normal S1 + S2, no m/g/r appreciated Lungs: CTAB, no wheezes, rales, rhonchi, crackles Abdomen: NABS, Soft, NTND, no rebound or guarding Ext: Pulses present, no pitting edema present Neuro: CNII-XII intact, no motor/sensory deficits elicited Pertinent Results: Admission labs: ================= [MASKED] 02:12AM BLOOD WBC-7.3 RBC-3.68* Hgb-10.0* Hct-30.7* MCV-83 MCH-27.2 MCHC-32.6 RDW-13.6 RDWSD-40.8 Plt [MASKED] [MASKED] 02:12AM BLOOD Neuts-87* Bands-5 Lymphs-2* Monos-5 Eos-0 Baso-1 [MASKED] Myelos-0 AbsNeut-6.72* AbsLymp-0.15* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.07 [MASKED] 02:12AM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-135 K-4.3 Cl-97 HCO3-25 AnGap-13 [MASKED] 02:12AM BLOOD ALT-56* AST-37 LD(LDH)-115 AlkPhos-61 Amylase-26 TotBili-0.3 [MASKED] 02:12AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.5 Mg-2.1 Iron-65 [MASKED] 02:12AM BLOOD calTIBC-202* VitB12-936* Ferritn-93 TRF-155* [MASKED] 02:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 02:12AM BLOOD CRP-8.7* [MASKED] 02:12AM BLOOD HIV Ab-NEG [MASKED] 02:12AM BLOOD HCV Ab-POS* [MASKED] 02:12AM BLOOD HCV VL-NOT DETECT [MASKED] 06:35PM BLOOD Lactate-2.1* ================ Discharge Labs: =================== [MASKED] 06:12AM BLOOD WBC-13.6* RBC-3.42* Hgb-9.5* Hct-29.1* MCV-85 MCH-27.8 MCHC-32.6 RDW-16.3* RDWSD-47.9* Plt [MASKED] [MASKED] 06:12AM BLOOD Glucose-124* UreaN-20 Creat-0.5 Na-137 K-4.5 Cl-100 HCO3-23 AnGap-14 [MASKED] 06:12AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0 [MASKED] 05:22AM BLOOD CRP-1.0 =============== Imaging: =============== [MASKED] CT Abdomen: There is massive dilatation of the transverse colon measuring up to 13.7 cm. This is similar to slightly progressed when compared to the prior study. The presence of air in the descending colon and rectum makes mechanical obstruction less likely. There is bowel wall edema evident in the descending colon consistent with the findings on the prior CT. There is loss of normal haustra pattern within the massively distended transverse colon. Toxic megacolon cannot be excluded however the time course with stability over a 6 day period is not typical. No free air seen. [MASKED] CXR (TB screen): The tip of the PICC projects over the distal SVC. There is no focal consolidation. There is no pleural effusion. The trachea is midline. The aorta is atherosclerotic and tortuous. Degenerative changes are evident in the spine. [MASKED] MRE enterography: 1. Active inflammation involving an approximately 8.0 cm segment of sigmoid colon, with wall thickening and pericolonic vascular prominence. 2. Subacute inflammation involving the rectum. Please note that the anal canal was not included on this examination. 3. Ahaustral dilated transverse colon and ahaustral nondilated descending colon, suggesting chronic inflammation. Focal narrowed caliber of the proximal transverse colon with the lumen measuring 1.3 cm, similar to prior CT. 4. No evidence of small bowel inflammation. 5. Fusiform 4.9 cm infrarenal abdominal aortic aneurysm. 6. Small bowel containing right inguinal hernia. No evidence of obstruction. ========== Micro: ========== [MASKED] Cdiff: Positive [MASKED] Stool culture: FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [MASKED]: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [MASKED]: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [MASKED]: NO E.COLI 0157:H7 FOUND. Path: [MASKED] rectal biopsy: 1. Rectum, biopsy: - Severe chronic active colitis with ulceration. - No granulomata or dysplasia identified. - Immunostain for CMV is negative. [MASKED] Rectal biopsy: Active colitis with ulceration ; granulomas or dysplasia not identified. Brief Hospital Course: [MASKED] M HCV-Ab positive, with Crohn's (on mesalamine and prednisone at home), readmitted to OSH for Crohns flare (received IV solumedrol and mesalamine, s/p colonoscopy), and transferred to [MASKED] for management of Crohns flare. #Crohn's flare- Presented with abdominal distension and diarrhea. Colonoscopy at OSH showed extensive ulcerative disease with path showing chronic active colitis. CT on admission showed rectosigmoid colitis, hepatic flexure inflammation and transverse colon distension. KUB with ~13cm distension of transverse colon. Evaluated by colorectal surgery without need for surgical intervention. Crohn's flare managed by IV solumedrom 20mg Q8hr. Flex sig showed inflammatory colitis and was negative for CMV colitis. Daily KUB and CRP showed improvement of colonic distension with CRP downtrending to 1.0. Attempted to obtain Humira but due to insurance issues was started on Remicaide with first dose on [MASKED] at 10mg/kg after screening evaluation for TB. Patient had no TB risk factors with negative CXR but quantiferon indeterminate given likely anergy from steroids. Diarrhea resolved and no longer blood in stool with stable H/H. He was on bowel rest with TPN with advancement to regular diet by discharge. Started on Prednisone 60mg prior to discharge with plan for taper down to 40mg after 5 days and continued taper per primary GI doctor, [MASKED]. Dr. [MASKED] was contacted and confirmed ability to continue Remicaide infusion outpatient in 2 weeks ([MASKED]) Plan is for next remicade dose at 2 weeks after initial, 5mg/kg, followed by another dose 4 weeks after that (6 weeks after first dose), then 5mg/kg every 8 weeks, with titration based on drug levels and clinical response. #C.diff Colitis- Bloody diarrhea on admission with negative stool cultures and positive for c.diff. Started on PO vanc and IV flagyl with resolution of diarrhea and bloody BM. Iv flagyl stopped on [MASKED] and patient was continued on PO vanc with plan for a total of 14 day course ([MASKED]) #cleared HCV- On screening prior to administration of Remicaide, he was found to be HCV ab positive with undetectable viral load. No risk factors or blood transfusions. Also was found to not be immunized for Hep B. Follow up with PCP for routine and immmunization for hep B. # AAA - CT scan reported mild interval enlargement of AAA but remained less than <5.5 cm with no symptoms or other concerning findings. Will follow up with PCP for close following and interval imaging. ======================= TRANSITIONAL ISSUES: ======================= MEDICATIONS: - New Meds: PO Vancomycin, Remicaide - Stopped Meds: None (mesalimine held) - Changed Meds: Prednisone 60mg FOLLOW-UP - Follow up: PCP, GI - [MASKED] required after discharge: Immunization for Hep B, monitoring of signs of cirrhosis given Hep C positive - Incidental findings: Not immunized for Hepatitis B - Follow up for management of AAA, 4.9 cm during this admission - Initial Remicaide dose on [MASKED]. Plan is for next remicade dose at 2 weeks after initial, 5mg/kg, followed by another dose 4 weeks after that (6 weeks after first dose), then 5mg/kg every 8 weeks, with titration based on drug levels and clinical response. - Continue PO Vanc for 14 day course for C.diff (end on [MASKED] OTHER ISSUES: # CONTACT:Wife [MASKED] [MASKED] # CODE: Full (confirmed) >30 min were spent on dc related activities Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apriso (mesalamine) 1.5 Gram oral DAILY 2. PredniSONE 60 mg PO DAILY 3. LOPERamide 2 mg PO TID:PRN Diarrhea Discharge Medications: 1. DICYCLOMine 10 mg PO TID RX *dicyclomine 10 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 2. PredniSONE 40 mg PO DAILY Start taking on [MASKED] after completing 60 mg RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*75 Tablet Refills:*0 3. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*12 Capsule Refills:*0 4. Apriso (mesalamine) 1.5 Gram oral DAILY 5. LOPERamide 2 mg PO TID:PRN Diarrhea Please do not take this medication while you have active c.diff and are under treatment for it 6. PredniSONE 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Crohn's flare Secondary diagnoses: Clostridum difficile colitis Severe Malnutrition Megacolon Abdominal Aortic aneurysm Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to [MASKED] because you had increased abdominal pain and diarrhea. You were found to have a Crohn's flare with significant distension of your colon and infection of your colon with a bacteria called Clostridium difficile. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your [MASKED] Care Team WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - Started on IV steroids - Given nutrition through IV to give your gut some rest - Had scopes done by GI to evaluate your colon inflammation - Give antibiotics (Vancomycin) for treatment of C.diff - Started on Remicaide for treatment of Crohn's flare - Changed IV steroids to pills - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with Dr. [MASKED] a week to schedule your next Remicaide infusion (1st dose on [MASKED] and next due 2 weeks after on [MASKED] - Please follow up with your primary care doctor and other health care providers (see below) - Please take all of your medications as prescribed (see below). - Seek medical attention if you have diarrhea, bloody stools, abdominal distension, increased abdominal pain, fever or other symptoms of concern. Followup Instructions: [MASKED]
[]
[ "Z87891", "Y92230" ]
[ "K50118: Crohn's disease of large intestine with other complication", "E43: Unspecified severe protein-calorie malnutrition", "A047: Enterocolitis due to Clostridium difficile", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "I714: Abdominal aortic aneurysm, without rupture", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,067,921
27,475,639
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Percocet / Oxycodone / Lidoderm / Ambien Attending: ___. Chief Complaint: Headache, dizziness Major Surgical or Invasive Procedure: ___ diagnostic cerebral angiogram History of Present Illness: ___ year old female presented to ___ with dizziness, and headache in the setting of past aneurysm s/p craniotomy for clipping. CT at OSH was negative for intracranial bleed, however an LP was unable to be completed. She was transferred to ___ for diagnostic angiogram. Past Medical History: Aneurysms x 2 GERD Hypertension (Uncontrolled) Breast Cancer Social History: ___ Family History: Unknown Physical Exam: ============= on admission: ============= PHYSICAL EXAM: Temp: 97.8 °F HR: 59, RR: 18, BP: 153/74, O2 sat: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. 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 ============= at discharge: ============= alert, oriented x3. PERRL. ___. EOMI. SAR ___. No drift. R groin site clean, dry intact. No hematoma. Sensation intact. Distal pulses 2+ Pertinent Results: please see OMR for pertinent results Brief Hospital Course: Ms. ___ is a ___ female with h/o past aneurysm clipping with Dr. ___ presented to OSH with headache. CTA was negative for hemorrhage and LP unable to be done due to scoliosis. She was transferred to ___ from OSH for angiogram. She was admitted to the ___ and taken to the angio suite on ___ for diagnostic cerebral angiogram. Angiogram was negative for aneurysm. Angioseal was unable to be placed, and she was maintained on flat bed rest for 6 hours post-procedure. No further intervention was indicated. She was transferred back to the ___ and remained stable overnight. On ___ she was tolerating PO diet, pain well controlled, and ambulating. She was discharged home in stable condition. No further follow-up with neurosurgery is required in the near future. Medications on Admission: Lamotrigine: 200mg PO qAM, 100mg PO qPM Pantoprazole 40mg daily tramadol, unknown dose valium 10mg daily Aspirin 81mg daily Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not exceed 6 tablets/day RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ capsule(s) by mouth every 6 hours as needed Disp #*30 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. LamoTRIgine 200 mg PO QAM 4. LamoTRIgine 100 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ ___ had an angiogram that showed no residual or new aneurysms. Head CT was also negative for bleeding. Activity · ___ may gradually return to your normal activities, but we recommend ___ take it easy for the next ___ hours to avoid bleeding from your groin. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. · ___ make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · Do not go swimming or submerge yourself in water for five (5) days after your procedure. · ___ make take a shower. Medications · Resume your normal medications and begin new medications as directed. · ___ may use Acetaminophen (Tylenol) for minor discomfort if ___ are not otherwise restricted from taking this medication. · If ___ take Metformin (Glucophage) ___ may start it again three (3) days after your procedure. Care of the Puncture Site · ___ will have a small bandage over the site. · Remove the bandage in 24 hours by soaking it with water and gently peeling it off. · Keep the site clean with soap and water and dry it carefully. · ___ may use a band-aid if ___ wish. What ___ ___ Experience: · Mild tenderness and bruising at the puncture site (groin). · Soreness in your arms from the intravenous lines. · Mild to moderate headaches that last several days to a few weeks. · Fatigue is very normal · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If ___ are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the puncture site. · Fever greater than 101.5 degrees Fahrenheit · Constipation · Blood in your stool or urine · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Followup Instructions: ___
[ "R51", "R42", "I10", "K219", "H3530", "F17210", "Z8679", "Z853" ]
Allergies: Percocet / Oxycodone / Lidoderm / Ambien Chief Complaint: Headache, dizziness Major Surgical or Invasive Procedure: [MASKED] diagnostic cerebral angiogram History of Present Illness: [MASKED] year old female presented to [MASKED] with dizziness, and headache in the setting of past aneurysm s/p craniotomy for clipping. CT at OSH was negative for intracranial bleed, however an LP was unable to be completed. She was transferred to [MASKED] for diagnostic angiogram. Past Medical History: Aneurysms x 2 GERD Hypertension (Uncontrolled) Breast Cancer Social History: [MASKED] Family History: Unknown Physical Exam: ============= on admission: ============= PHYSICAL EXAM: Temp: 97.8 °F HR: 59, RR: 18, BP: 153/74, O2 sat: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. 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 ============= at discharge: ============= alert, oriented x3. PERRL. [MASKED]. EOMI. SAR [MASKED]. No drift. R groin site clean, dry intact. No hematoma. Sensation intact. Distal pulses 2+ Pertinent Results: please see OMR for pertinent results Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with h/o past aneurysm clipping with Dr. [MASKED] presented to OSH with headache. CTA was negative for hemorrhage and LP unable to be done due to scoliosis. She was transferred to [MASKED] from OSH for angiogram. She was admitted to the [MASKED] and taken to the angio suite on [MASKED] for diagnostic cerebral angiogram. Angiogram was negative for aneurysm. Angioseal was unable to be placed, and she was maintained on flat bed rest for 6 hours post-procedure. No further intervention was indicated. She was transferred back to the [MASKED] and remained stable overnight. On [MASKED] she was tolerating PO diet, pain well controlled, and ambulating. She was discharged home in stable condition. No further follow-up with neurosurgery is required in the near future. Medications on Admission: Lamotrigine: 200mg PO qAM, 100mg PO qPM Pantoprazole 40mg daily tramadol, unknown dose valium 10mg daily Aspirin 81mg daily Discharge Medications: 1. Acetaminophen-Caff-Butalbital [MASKED] TAB PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not exceed 6 tablets/day RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [MASKED] capsule(s) by mouth every 6 hours as needed Disp #*30 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. LamoTRIgine 200 mg PO QAM 4. LamoTRIgine 100 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. [MASKED] [MASKED] had an angiogram that showed no residual or new aneurysms. Head CT was also negative for bleeding. Activity · [MASKED] may gradually return to your normal activities, but we recommend [MASKED] take it easy for the next [MASKED] hours to avoid bleeding from your groin. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. · [MASKED] make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. · Do not go swimming or submerge yourself in water for five (5) days after your procedure. · [MASKED] make take a shower. Medications · Resume your normal medications and begin new medications as directed. · [MASKED] may use Acetaminophen (Tylenol) for minor discomfort if [MASKED] are not otherwise restricted from taking this medication. · If [MASKED] take Metformin (Glucophage) [MASKED] may start it again three (3) days after your procedure. Care of the Puncture Site · [MASKED] will have a small bandage over the site. · Remove the bandage in 24 hours by soaking it with water and gently peeling it off. · Keep the site clean with soap and water and dry it carefully. · [MASKED] may use a band-aid if [MASKED] wish. What [MASKED] [MASKED] Experience: · Mild tenderness and bruising at the puncture site (groin). · Soreness in your arms from the intravenous lines. · Mild to moderate headaches that last several days to a few weeks. · Fatigue is very normal · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If [MASKED] are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at [MASKED] for: · Severe pain, swelling, redness or drainage from the puncture site. · Fever greater than 101.5 degrees Fahrenheit · Constipation · Blood in your stool or urine · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Followup Instructions: [MASKED]
[]
[ "I10", "K219", "F17210" ]
[ "R51: Headache", "R42: Dizziness and giddiness", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "H3530: Unspecified macular degeneration", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8679: Personal history of other diseases of the circulatory system", "Z853: Personal history of malignant neoplasm of breast" ]
10,068,177
20,531,889
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 ankle fracture Major Surgical or Invasive Procedure: Open reduction and internal fixation of left ankle History of Present Illness: ___ female presents with the above fracture s/p mechanical fall. Patient was walking downhill with her sister's dog and slipped on some wet leaves that were covering dark. Patient felt immediate pain in her left ankle without associated numbness or tingling. Patient initially went to outside hospital where an x-ray showed a left trimalleolar fracture and she was transferred here for further examination. Patient denies any head strike, numbness, weakness, tingling. Past Medical History: hypothyroidism Social History: ___ Family History: non-contributory Physical Exam: GEN: well appearing, NAD CV: regular rate PULM: non-labored breathing on room air Left lower extremity: - Splint in place, clean and dry - SILT sural/saphenous/tibial/deep peroneal/superficial peroneal distributions - Firing ___ - Warm and well perfused, +dorsalis pedis pulse Pertinent Results: ___ WBC-9.2 RBC-3.46* Hgb-10.5* Hct-32.3* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.0 RDWSD-44.1 Plt ___ Glucose-98 UreaN-16 Creat-1.0 Na-143 K-3.9 Cl-105 HCO3-28 AnGap-10 Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for open reduction internal fixation of left ankle, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non-weightbearing in splint in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Beclomethasone Dipro. AQ (Nasal) 40 mcg/actuation nasal BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC Q24H 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 6. Senna 8.6 mg PO BID 7. Vitamin D 1000 UNIT PO DAILY 8. Beclomethasone Dipro. AQ (Nasal) 40 mcg/actuation nasal BID 9. Citalopram 20 mg PO DAILY 10. Levothyroxine Sodium 125 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left trimalleolar ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing to left lower extremity short leg splint MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever >101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
[ "S82852A", "W010XXA", "Y93K1", "Y929", "E039" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left ankle fracture Major Surgical or Invasive Procedure: Open reduction and internal fixation of left ankle History of Present Illness: [MASKED] female presents with the above fracture s/p mechanical fall. Patient was walking downhill with her sister's dog and slipped on some wet leaves that were covering dark. Patient felt immediate pain in her left ankle without associated numbness or tingling. Patient initially went to outside hospital where an x-ray showed a left trimalleolar fracture and she was transferred here for further examination. Patient denies any head strike, numbness, weakness, tingling. Past Medical History: hypothyroidism Social History: [MASKED] Family History: non-contributory Physical Exam: GEN: well appearing, NAD CV: regular rate PULM: non-labored breathing on room air Left lower extremity: - Splint in place, clean and dry - SILT sural/saphenous/tibial/deep peroneal/superficial peroneal distributions - Firing [MASKED] - Warm and well perfused, +dorsalis pedis pulse Pertinent Results: [MASKED] WBC-9.2 RBC-3.46* Hgb-10.5* Hct-32.3* MCV-93 MCH-30.3 MCHC-32.5 RDW-13.0 RDWSD-44.1 Plt [MASKED] Glucose-98 UreaN-16 Creat-1.0 Na-143 K-3.9 Cl-105 HCO3-28 AnGap-10 Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on [MASKED] for open reduction internal fixation of left ankle, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non-weightbearing in splint in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Beclomethasone Dipro. AQ (Nasal) 40 mcg/actuation nasal BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC Q24H 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 6. Senna 8.6 mg PO BID 7. Vitamin D 1000 UNIT PO DAILY 8. Beclomethasone Dipro. AQ (Nasal) 40 mcg/actuation nasal BID 9. Citalopram 20 mg PO DAILY 10. Levothyroxine Sodium 125 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left trimalleolar ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing to left lower extremity short leg splint MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever >101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: [MASKED]
[]
[ "Y929", "E039" ]
[ "S82852A: Displaced trimalleolar fracture of left lower leg, initial encounter for closed fracture", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y93K1: Activity, walking an animal", "Y929: Unspecified place or not applicable", "E039: Hypothyroidism, unspecified" ]
10,068,741
22,137,833
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath and weight gain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ woman with hypertension, chronic atrial fibrillation, mildly dilated ascending aorta and aortic arch, valvular heart disease, who presented with dyspnea for 1 week. The patient lives alone, and has her son intermittently check on her. She has been intermittently noncompliant with home medications, including furosemide. She herself reports poor compliance over the preceding few days and complains of bilateral lower extremity edema, dyspnea and lower back pain. Of note, she recently returned from a trip to ___. She denied any recent fevers, chills, or productive cough. She does have a non-productive cough. During this trip, she ate out at many restaurants while in ___ for 3 weeks. Her son also adds that she drinks a lot of water at home. In the ED, initial VS were: pain ___, T 97, HR 140, BP 148/111, R 24, SpO2 100%/NC. Discussion with translator was difficult, as patient speaks a rural dialect of ___, per her son. - On arrival, she was in AF with RVR, which responded well to IV diltiazem and diuresis. - Labs were significant for pro-BNP 7933, AST/ALT 55/33, ALP 45, total bilirubin 1.3, Na 138, K 3.6, Cr 1.1, Phos 4.9, lactate initially 3.1, though trended down to 1.9 post diuresis, WBC 8.2, INR 1.2 - CXR showed right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. - Given ASA 324, nitroglycerin SL, furosemide 40 mg IV, diltiazem 10 mg IV - She had 1.3 L urine output to the 40 mg IV furosemide dose On arrival to the floor, patient reports no complaints. Past Medical History: - Chronic diastolic heart failure - Hypertension - Atrial fibrillation, CHADS-Vasc 4, on dabigatran - Mildly dilated ascending aorta (4 cm) and aortic notch (3.2 cm) - Valvular heart disease, characterized by ___ MR & 2+ TR Social History: ___ Family History: no known family history of cardiac disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITALS: T 98, BP 137/105, HR 109, R 20, Spo2 100%/2L NC, admission weight 53.8 kg, UOP 170 cc (after 1.3L emptied in ED, after 40 mg IV furosemide) GENERAL: mildly uncomfortable appearing, pleasant, laying in bed at 30 degree angle HEENT: PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK: prominent, yet reducible bulge noted on the lower R aspect of the neck (likely large distension of the EJV), with JVP visible above the ear lobe CARDIAC: irregular, normal S1 & S2 without murmurs PULMONARY: crackles bilaterally, up to half way up lung fields ABDOMEN: soft, tender in RUQ, though negative ___ sign, hepatomegaly, no splenomegaly, normal bowel sounds EXTREMITIES: 3+ pitting edema to the knee, all extremities warm, DP pulses 2+ bilaterally NEURO: alert & oriented to name, month/year, hospital, ___ - face symmetric, tongue protrudes midline, palate elevates midline, moves all extremities well DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 108/72 (99-118/68-78) 74 (70-130s) 18 94% RA Wt: 45.0<--45.3<--45.8<--45.7<--46.8<--47.7<-48.2<--49.2<--admission weight 53.8 kg I/O: 180/500; ___ GENERAL: Sitting comfortably in bed, N.C in place, NAD HEENT: PERRL, EOMI, sclerae anicteric, MMM NECK: Supple, JVP mild elevated 8 cm CARDIAC: irregularly irregular, normal S1 & S2 without murmurs PULMONARY: poor inspiratory effort, CTAB, no wheezes ABDOMEN: soft, ND, NTTP, +BS EXTREMITIES: trace edema to the mid-shin, all extremities warm, DP pulses 2+ bilaterally NEURO: CN II-XII grossly intact, moving all extremities with purpose, non-focal exam Pertinent Results: ADMISSION LABS: ================ ___ 11:15PM BLOOD WBC-8.2# RBC-5.21* Hgb-16.0* Hct-48.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* RDWSD-52.3* Plt ___ ___ 11:15PM BLOOD Neuts-78.4* Lymphs-13.9* Monos-6.7 Eos-0.1* Baso-0.4 Im ___ AbsNeut-6.44* AbsLymp-1.14* AbsMono-0.55 AbsEos-0.01* AbsBaso-0.03 ___ 11:15PM BLOOD ___ PTT-33.3 ___ ___ 11:15PM BLOOD Glucose-203* UreaN-25* Creat-1.2* Na-131* K-GREATER TH Cl-100 HCO3-21* ___ 11:15PM BLOOD ALT-46* AST-171* AlkPhos-33* TotBili-1.5 ___ 11:15PM BLOOD proBNP-7933* ___ 11:15PM BLOOD cTropnT-0.04* ___ 11:15PM BLOOD Albumin-4.3 Calcium-8.7 Phos-5.7* Mg-2.4 Troponin Trend: ================ ___ 03:30AM BLOOD cTropnT-0.05* proBNP-6574* ___ 02:35AM BLOOD CK-MB-4 cTropnT-0.05* ___ 08:40AM BLOOD cTropnT-0.04* Lactate Trend: ================= ___ 11:24PM BLOOD Lactate-4.9* K-8.5* ___ 01:05AM BLOOD Lactate-3.1* ___ 03:37AM BLOOD Lactate-1.9 ___ 02:40AM BLOOD Lactate-3.1* ___ 11:08AM BLOOD Lactate-2.5* ___ 05:07PM BLOOD Lactate-2.9* ___ 08:16AM BLOOD Lactate-2.2* Other Pertinent Labs: ======================= ___ 12:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE ___ 12:45AM BLOOD HCV Ab-NEGATIVE Micro: ======= ___ 10:22 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Imaging: ========= ___ CXR Right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. TTE ___: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is mildly increased. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small to moderate sized circumferential pericardial effusion without evidence of hemodynamic compromise. IMPRESSION: Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Pulmonary artery hypertension. Mild-moderate aortic regurgitation. Right ventricular cavity dilation with preserved free wall motion. Dilated ascending aorta. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation has increased and the pericardial effusion is slightly smaller. The estimated PA systolic pressure is now slightly lower. RUQ U/S ___: 1. No focal liver lesion identified. Hepatopetal flow in the main portal vein which is noted to be hyperdynamic which can be seen in the setting of CHF. 2. Small bilateral pleural effusions and scant trace of ascites in the abdomen. 3. Small nonobstructing stone incidentally noted in the right kidney. DISCHARGE LABS: ================ ___ 05:56AM BLOOD WBC-8.8 RBC-4.65 Hgb-14.3 Hct-42.9 MCV-92 MCH-30.8 MCHC-33.3 RDW-15.1 RDWSD-50.0* Plt ___ ___ 05:56AM BLOOD Plt ___ ___ 05:56AM BLOOD ___ PTT-35.7 ___ ___ 05:56AM BLOOD Glucose-81 UreaN-29* Creat-0.7 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 ___ 05:56AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1 MICRO: ====== Urine Culture x 2: No growth. Blood Culture x 2: NGTD (___) Brief Hospital Course: Ms. ___ is an ___ year old female with PMH chronic atrial fibrillation, hypertension and diastolic heart failure who presented with dyspnea and worsening lower extremity edema consistent with an acute on chronic exacerbation of CHF in the setting of dietary and medication non-compliance. Upon admission, BNP 6574 and troponin trend 0.05, 0.05, 0.04. EKG notable for atrial fibrillation, but no evidence of active ischemia. Repeat TTE showed LVEF >55% with mod-severe MR, mod-severe TR, PA HTN and dilated RV. She was successfully diuresed with lasix 40mg IV daily to BID which was later transitioned to 20 mg PO daily (her home dose) Of note, the patient has chronic atrial fibrillation. During her hospital stay, her dabigatran was changed to apixaban due to a more favorable safety profile. In addition her metoprolol was increased to 100mg BID and diltiazem ER 120 mg was added for rate control. She felt well on the day of discharge. # ACUTE ON CHRONIC DIASTOLIC HEART FAILURE. The patient presented with a one week history of worsening shortness of breath and lower extremity edema consistent with an acute exacerbation of her dCHF in the setting of dietary and medication non-compliance. Of note, the patient was recently in ___ where she was eating out a lot, drinking lots of water, and not taking her medications as prescribed. When she returned to the ___, her dyspnea and ___ worsened at which point she presented to the hospital. Upon admission, BNP eleavted to ___ with CXR showing e/o pulmonary edema. Troponins flat at 0.05, 0.05 and 0.04 and EKG negative for evidence of acute ischemia. TTE showed preserved LVEF >55% with mod-severe MR, TR and pulmonary hypertension. Nutrition saw the patient and outlined a low sodium diet for the patient and her family and the importance of dietary and medication compliance was emphasized. She was successfully diuresed with lasix 40mg IV once to twice daily with close monitoring of her daily weights and I/O's. She was transitioned to lasix 20 mg PO upon discharge. In addition, lisinopril 15mg daily was added and her metop was uptitrated to 100mg BID. Discharge weight: 45 kg (99 lbs) # ATRIAL FIBRILLATION CHADs-vasc 6. The patient has a history of chronic atrial fibrillation initially on dabigatran and metoprolol for rate control. Upon presentation, the she was noted to be in Afib with RVR with rates in the 140s which responded well to diltiazem 10mg IV. Throughout her hospital stay, the patient's metoprolol was up-titrated to 100mg BID and diltiazem ER 120 was added for better rate control. In addition, her dabigatran was changed to apixaban 2.5mg BID for anticoagulation given the more favorable safety profile. She is on low dose due to her age > ___ and her weight < 60 kgs. # ELEVATED TRANSAMINASES. The patient's LFTs were elevated upon admission in the setting of recent travel abroad and acute dCHF exacerbation. RUQ ultrasound unremarkable and hepatitis serologies negative. Likely congestive hepatopathy from acute on chronic diastolic heart failure and her LFTs downtrended with diuresis. # HYPERTENSION. The patient was admitted with diastolic BP >100 in the setting of medication non-compliance. Her pressures normalized with the initiation of lisinopril 15mg daily and diltiazem ER 120 daily. Her metoprolol was up-titrated to 100mg BID. # ?UTI: UA upon admission concerning for urinary tract infection. She was initiated on ceftriaxone which was later discontinued on ___ when urine culture returned negative. Transitional Issues: ===================== -Patient speaks a rural dialect of ___ only -Continued home dose Lasix 20 mg after adequate diuresis. -Increased metoprolol to 100mg XL BID and added Diltiazem 120 mg ER for better rate control -Started lisinopril 15mg daily -Changed dabigatran to apixaban 2.5mg BID for anticoagulation given more favorable safety profile (reason for reduced [2.5mg] dosing is due to age > ___ and weight less than 60kg) -Discharge weight: 45.0 kg (99 lbs) -Code: Full -Contact: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 2. Metoprolol Succinate XL 100 mg PO Q12H RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 3. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 4. Diltiazem Extended-Release 120 mg PO DAILY RX *diltiazem HCl [Cardizem CD] 120 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3 5. Lisinopril 15 mg PO DAILY RX *lisinopril 30 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*15 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Congestive Heart Failure, Atrial Fibrillation Secondary: 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. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted for the shortness of breath and weight gain you were experiencing. Your symptoms were due to an exacerbation of your congestive heart failure. Throughout your hospital stay, you were given medication to help remove the extra fluid from your body. In addition, you were placed on a different blood thinner, called apixaban for your atrial fibrillation. To help control your fast heart rate, we have increased your metoprolol to 100mg twice daily and added a new medication called diltiazem. It is very important to take your water pill, or lasix, and heart medications everyday to help prevent fluid from building back up in your body. In addition, eating a diet that is low in salt and limiting your fluid intake to 2L per day will also help prevent your symptoms from recurring. Please weigh yourself everyday and call the doctor if you gain >3 lbs. Best Wishes, Your ___ Team Followup Instructions: ___
[ "I5033", "I272", "I4891", "I10", "Z7901", "J449", "K761", "I77819", "R0902", "I340", "I071", "Z9111", "Z9114" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Shortness of breath and weight gain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is an [MASKED] woman with hypertension, chronic atrial fibrillation, mildly dilated ascending aorta and aortic arch, valvular heart disease, who presented with dyspnea for 1 week. The patient lives alone, and has her son intermittently check on her. She has been intermittently noncompliant with home medications, including furosemide. She herself reports poor compliance over the preceding few days and complains of bilateral lower extremity edema, dyspnea and lower back pain. Of note, she recently returned from a trip to [MASKED]. She denied any recent fevers, chills, or productive cough. She does have a non-productive cough. During this trip, she ate out at many restaurants while in [MASKED] for 3 weeks. Her son also adds that she drinks a lot of water at home. In the ED, initial VS were: pain [MASKED], T 97, HR 140, BP 148/111, R 24, SpO2 100%/NC. Discussion with translator was difficult, as patient speaks a rural dialect of [MASKED], per her son. - On arrival, she was in AF with RVR, which responded well to IV diltiazem and diuresis. - Labs were significant for pro-BNP 7933, AST/ALT 55/33, ALP 45, total bilirubin 1.3, Na 138, K 3.6, Cr 1.1, Phos 4.9, lactate initially 3.1, though trended down to 1.9 post diuresis, WBC 8.2, INR 1.2 - CXR showed right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. - Given ASA 324, nitroglycerin SL, furosemide 40 mg IV, diltiazem 10 mg IV - She had 1.3 L urine output to the 40 mg IV furosemide dose On arrival to the floor, patient reports no complaints. Past Medical History: - Chronic diastolic heart failure - Hypertension - Atrial fibrillation, CHADS-Vasc 4, on dabigatran - Mildly dilated ascending aorta (4 cm) and aortic notch (3.2 cm) - Valvular heart disease, characterized by [MASKED] MR & 2+ TR Social History: [MASKED] Family History: no known family history of cardiac disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITALS: T 98, BP 137/105, HR 109, R 20, Spo2 100%/2L NC, admission weight 53.8 kg, UOP 170 cc (after 1.3L emptied in ED, after 40 mg IV furosemide) GENERAL: mildly uncomfortable appearing, pleasant, laying in bed at 30 degree angle HEENT: PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK: prominent, yet reducible bulge noted on the lower R aspect of the neck (likely large distension of the EJV), with JVP visible above the ear lobe CARDIAC: irregular, normal S1 & S2 without murmurs PULMONARY: crackles bilaterally, up to half way up lung fields ABDOMEN: soft, tender in RUQ, though negative [MASKED] sign, hepatomegaly, no splenomegaly, normal bowel sounds EXTREMITIES: 3+ pitting edema to the knee, all extremities warm, DP pulses 2+ bilaterally NEURO: alert & oriented to name, month/year, hospital, [MASKED] - face symmetric, tongue protrudes midline, palate elevates midline, moves all extremities well DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 108/72 (99-118/68-78) 74 (70-130s) 18 94% RA Wt: 45.0<--45.3<--45.8<--45.7<--46.8<--47.7<-48.2<--49.2<--admission weight 53.8 kg I/O: 180/500; [MASKED] GENERAL: Sitting comfortably in bed, N.C in place, NAD HEENT: PERRL, EOMI, sclerae anicteric, MMM NECK: Supple, JVP mild elevated 8 cm CARDIAC: irregularly irregular, normal S1 & S2 without murmurs PULMONARY: poor inspiratory effort, CTAB, no wheezes ABDOMEN: soft, ND, NTTP, +BS EXTREMITIES: trace edema to the mid-shin, all extremities warm, DP pulses 2+ bilaterally NEURO: CN II-XII grossly intact, moving all extremities with purpose, non-focal exam Pertinent Results: ADMISSION LABS: ================ [MASKED] 11:15PM BLOOD WBC-8.2# RBC-5.21* Hgb-16.0* Hct-48.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* RDWSD-52.3* Plt [MASKED] [MASKED] 11:15PM BLOOD Neuts-78.4* Lymphs-13.9* Monos-6.7 Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-6.44* AbsLymp-1.14* AbsMono-0.55 AbsEos-0.01* AbsBaso-0.03 [MASKED] 11:15PM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 11:15PM BLOOD Glucose-203* UreaN-25* Creat-1.2* Na-131* K-GREATER TH Cl-100 HCO3-21* [MASKED] 11:15PM BLOOD ALT-46* AST-171* AlkPhos-33* TotBili-1.5 [MASKED] 11:15PM BLOOD proBNP-7933* [MASKED] 11:15PM BLOOD cTropnT-0.04* [MASKED] 11:15PM BLOOD Albumin-4.3 Calcium-8.7 Phos-5.7* Mg-2.4 Troponin Trend: ================ [MASKED] 03:30AM BLOOD cTropnT-0.05* proBNP-6574* [MASKED] 02:35AM BLOOD CK-MB-4 cTropnT-0.05* [MASKED] 08:40AM BLOOD cTropnT-0.04* Lactate Trend: ================= [MASKED] 11:24PM BLOOD Lactate-4.9* K-8.5* [MASKED] 01:05AM BLOOD Lactate-3.1* [MASKED] 03:37AM BLOOD Lactate-1.9 [MASKED] 02:40AM BLOOD Lactate-3.1* [MASKED] 11:08AM BLOOD Lactate-2.5* [MASKED] 05:07PM BLOOD Lactate-2.9* [MASKED] 08:16AM BLOOD Lactate-2.2* Other Pertinent Labs: ======================= [MASKED] 12:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [MASKED] 12:45AM BLOOD HCV Ab-NEGATIVE Micro: ======= [MASKED] 10:22 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. Imaging: ========= [MASKED] CXR Right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. TTE [MASKED]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([MASKED]) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is mildly increased. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small to moderate sized circumferential pericardial effusion without evidence of hemodynamic compromise. IMPRESSION: Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Pulmonary artery hypertension. Mild-moderate aortic regurgitation. Right ventricular cavity dilation with preserved free wall motion. Dilated ascending aorta. Compared with the prior study (images reviewed) of [MASKED], the severity of mitral regurgitation has increased and the pericardial effusion is slightly smaller. The estimated PA systolic pressure is now slightly lower. RUQ U/S [MASKED]: 1. No focal liver lesion identified. Hepatopetal flow in the main portal vein which is noted to be hyperdynamic which can be seen in the setting of CHF. 2. Small bilateral pleural effusions and scant trace of ascites in the abdomen. 3. Small nonobstructing stone incidentally noted in the right kidney. DISCHARGE LABS: ================ [MASKED] 05:56AM BLOOD WBC-8.8 RBC-4.65 Hgb-14.3 Hct-42.9 MCV-92 MCH-30.8 MCHC-33.3 RDW-15.1 RDWSD-50.0* Plt [MASKED] [MASKED] 05:56AM BLOOD Plt [MASKED] [MASKED] 05:56AM BLOOD [MASKED] PTT-35.7 [MASKED] [MASKED] 05:56AM BLOOD Glucose-81 UreaN-29* Creat-0.7 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 [MASKED] 05:56AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1 MICRO: ====== Urine Culture x 2: No growth. Blood Culture x 2: NGTD ([MASKED]) Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old female with PMH chronic atrial fibrillation, hypertension and diastolic heart failure who presented with dyspnea and worsening lower extremity edema consistent with an acute on chronic exacerbation of CHF in the setting of dietary and medication non-compliance. Upon admission, BNP 6574 and troponin trend 0.05, 0.05, 0.04. EKG notable for atrial fibrillation, but no evidence of active ischemia. Repeat TTE showed LVEF >55% with mod-severe MR, mod-severe TR, PA HTN and dilated RV. She was successfully diuresed with lasix 40mg IV daily to BID which was later transitioned to 20 mg PO daily (her home dose) Of note, the patient has chronic atrial fibrillation. During her hospital stay, her dabigatran was changed to apixaban due to a more favorable safety profile. In addition her metoprolol was increased to 100mg BID and diltiazem ER 120 mg was added for rate control. She felt well on the day of discharge. # ACUTE ON CHRONIC DIASTOLIC HEART FAILURE. The patient presented with a one week history of worsening shortness of breath and lower extremity edema consistent with an acute exacerbation of her dCHF in the setting of dietary and medication non-compliance. Of note, the patient was recently in [MASKED] where she was eating out a lot, drinking lots of water, and not taking her medications as prescribed. When she returned to the [MASKED], her dyspnea and [MASKED] worsened at which point she presented to the hospital. Upon admission, BNP eleavted to [MASKED] with CXR showing e/o pulmonary edema. Troponins flat at 0.05, 0.05 and 0.04 and EKG negative for evidence of acute ischemia. TTE showed preserved LVEF >55% with mod-severe MR, TR and pulmonary hypertension. Nutrition saw the patient and outlined a low sodium diet for the patient and her family and the importance of dietary and medication compliance was emphasized. She was successfully diuresed with lasix 40mg IV once to twice daily with close monitoring of her daily weights and I/O's. She was transitioned to lasix 20 mg PO upon discharge. In addition, lisinopril 15mg daily was added and her metop was uptitrated to 100mg BID. Discharge weight: 45 kg (99 lbs) # ATRIAL FIBRILLATION CHADs-vasc 6. The patient has a history of chronic atrial fibrillation initially on dabigatran and metoprolol for rate control. Upon presentation, the she was noted to be in Afib with RVR with rates in the 140s which responded well to diltiazem 10mg IV. Throughout her hospital stay, the patient's metoprolol was up-titrated to 100mg BID and diltiazem ER 120 was added for better rate control. In addition, her dabigatran was changed to apixaban 2.5mg BID for anticoagulation given the more favorable safety profile. She is on low dose due to her age > [MASKED] and her weight < 60 kgs. # ELEVATED TRANSAMINASES. The patient's LFTs were elevated upon admission in the setting of recent travel abroad and acute dCHF exacerbation. RUQ ultrasound unremarkable and hepatitis serologies negative. Likely congestive hepatopathy from acute on chronic diastolic heart failure and her LFTs downtrended with diuresis. # HYPERTENSION. The patient was admitted with diastolic BP >100 in the setting of medication non-compliance. Her pressures normalized with the initiation of lisinopril 15mg daily and diltiazem ER 120 daily. Her metoprolol was up-titrated to 100mg BID. # ?UTI: UA upon admission concerning for urinary tract infection. She was initiated on ceftriaxone which was later discontinued on [MASKED] when urine culture returned negative. Transitional Issues: ===================== -Patient speaks a rural dialect of [MASKED] only -Continued home dose Lasix 20 mg after adequate diuresis. -Increased metoprolol to 100mg XL BID and added Diltiazem 120 mg ER for better rate control -Started lisinopril 15mg daily -Changed dabigatran to apixaban 2.5mg BID for anticoagulation given more favorable safety profile (reason for reduced [2.5mg] dosing is due to age > [MASKED] and weight less than 60kg) -Discharge weight: 45.0 kg (99 lbs) -Code: Full -Contact: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 2. Metoprolol Succinate XL 100 mg PO Q12H RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 3. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 4. Diltiazem Extended-Release 120 mg PO DAILY RX *diltiazem HCl [Cardizem CD] 120 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3 5. Lisinopril 15 mg PO DAILY RX *lisinopril 30 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*15 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Congestive Heart Failure, Atrial Fibrillation Secondary: 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], It was a pleasure taking care of you during your stay at [MASKED] [MASKED]. You were admitted for the shortness of breath and weight gain you were experiencing. Your symptoms were due to an exacerbation of your congestive heart failure. Throughout your hospital stay, you were given medication to help remove the extra fluid from your body. In addition, you were placed on a different blood thinner, called apixaban for your atrial fibrillation. To help control your fast heart rate, we have increased your metoprolol to 100mg twice daily and added a new medication called diltiazem. It is very important to take your water pill, or lasix, and heart medications everyday to help prevent fluid from building back up in your body. In addition, eating a diet that is low in salt and limiting your fluid intake to 2L per day will also help prevent your symptoms from recurring. Please weigh yourself everyday and call the doctor if you gain >3 lbs. Best Wishes, Your [MASKED] Team Followup Instructions: [MASKED]
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[ "I4891", "I10", "Z7901", "J449" ]
[ "I5033: Acute on chronic diastolic (congestive) heart failure", "I272: Other secondary pulmonary hypertension", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "Z7901: Long term (current) use of anticoagulants", "J449: Chronic obstructive pulmonary disease, unspecified", "K761: Chronic passive congestion of liver", "I77819: Aortic ectasia, unspecified site", "R0902: Hypoxemia", "I340: Nonrheumatic mitral (valve) insufficiency", "I071: Rheumatic tricuspid insufficiency", "Z9111: Patient's noncompliance with dietary regimen", "Z9114: Patient's other noncompliance with medication regimen" ]